About

If getting pregnant has been a challenge for you and your partner, you’re not alone. Ten percent to 15 percent of couples in the United States are infertile. Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year.

If you’ve been trying to conceive for more than a year, there’s a chance that something may be interfering with your efforts to have a child. Infertility may be due to a single cause in either you or your partner, or a combination of factors that may prevent a pregnancy from occurring or continuing.

What is Infertility?

Most experts define infertility as not being able to get pregnant after at least one year of trying. Women who are able to get pregnant but then have repeat miscarriages are also said to be infertile.

Pregnancy is the result of a complex chain of events. In order to get pregnant:

A woman must release an egg from one of her ovaries (ovulation).

The egg must go through a fallopian tube toward the uterus (womb).

A man’s sperm must join with (fertilize) the egg along the way.

The fertilized egg must attach to the inside of the uterus (implantation).

Infertility can result from problems that interfere with any of these steps.

Causes

Percentage

Ovulatory failure (including Polycystic Ovary Syndrome)

20

Tubal damage

15

Endometriosis

5

Male problems

26

Unexplained

30

In Male

A number of causes exist for male infertility that may result in impaired sperm count or mobility, or impaired ability to fertilize the egg. The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm, conditions related to a man’s general health and lifestyle, and overexposure to certain environmental elements:

Abnormal Sperm Production or Function.

Most cases of male infertility are due to sperm abnormalities, such as:

Impaired shape and movement of sperm. Sperm must be properly shaped and able to move rapidly and accurately toward the egg for fertilization to occur. If the shape and structure (morphology) of the sperm are abnormal or the movement (motility) is impaired, sperm may not be able to reach the egg.

Absent sperm production in testicles. Complete failure of the testicles to produce sperm is rare, affecting very few infertile men.

Low sperm concentration. A normal sperm concentration is greater than or equal to 20 million sperm per milliliter of semen. A count of 10 million or fewer sperm per milliliter of semen indicates low sperm concentration (subfertility). A count of 40 million sperm or higher per milliliter of semen indicates increased fertility.

Varicocele. A varicocele is a varicose vein in the scrotum that may prevent normal cooling of the testicle and raise testicular temperature, preventing sperm from surviving.

Undescended testicle (cryptorchidism). This occurs when one or both testicles fail to descend from the abdomen into the scrotum during fetal development. Undescended testicles can cause mild to severely impaired sperm production. Because the testicles are exposed to the higher internal body temperature compared to the temperature in the scrotum, sperm production may be affected.

Testosterone deficiency (male hypogonadism). Infertility can result from disorders of the testicles themselves, or an abnormality affecting the hypothalamus or pituitary glands in the brain that produce the hormones that control the testicles.

Klinefelter’s syndrome. In this disorder of the sex chromosomes, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production. Testosterone production also may be lower.

Infections. Infection may temporarily affect sperm motility. Repeated bouts of sexually transmitted diseases (STDs), such as chlamydia and gonorrhea, are most often associated with male infertility. These infections can cause scarring and block sperm passage. Mycoplasma is an organism that may fasten itself to sperm cells, making them less motile. If mumps, a viral infection usually affecting young children, occurs after puberty, inflammation of the testicles can impair sperm production. Inflammation of the prostate (prostatitis), urethra or epididymis also may alter sperm motility.

In many instances, no cause for reduced sperm production is found. When sperm concentration is less than 5 million per milliliter of semen, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome.

Impaired Delivery of Sperm

Problems with the delivery of sperm from the penis into the vagina can cause infertility. These may include:

Sexual issues. Often treatable, problems with sexual intercourse or technique may affect fertility. Difficulties with erection of the penis (erectile dysfunction), premature ejaculation, painful intercourse (dyspareunia), or psychological or relationship problems can contribute to infertility. Use of lubricants such as oils or petroleum jelly can be toxic to sperm and impair fertility.

Retrograde ejaculation. This occurs when semen enters the bladder during orgasm rather than emerging out through the penis. Various conditions can cause retrograde ejaculation including diabetes, bladder, prostate or urethral surgery, and the use of psychiatric or antihypertensive drugs.

Blockage of epididymis or ejaculatory ducts. Some men are born with blockage of the part of the testicle that contains sperm (epididymis) or ejaculatory ducts. And some men who seek treatment for infertility lack the tubes that carry sperm (vasa deferentia).

No semen (ejaculate). The absence of ejaculate may occur in men with spinal cord injuries or diseases. This fluid transports sperm through the penis into the vagina.

Misplaced urinary opening (hypospadias). A birth defect can cause the urinary (urethral) opening to be abnormally located on the underside of the penis. If not surgically corrected, this condition can prevent sperm from reaching the cervix.

Anti-sperm antibodies. Antibodies that target sperm and weaken or disable them usually occur after surgical blockage of part of the vas deferens for male sterilization (vasectomy). Presence of these antibodies may complicate the reversal of a vasectomy.

Cystic fibrosis. Men with cystic fibrosis often have missing or obstructed vasa deferentia.

SPERM

SPERM

Average body’s production

50,000 per minute/72 million per day (and remember lads, it only takes 1)

Days to maturity

84

Number in ejaculate of average fertile man

200 to 600 million

Number of ejaculate of infertile man

less than 50 million

Percentage of total ejaculate

3% – 5%

Average swimming speed

1 to 4 millimeters per minute

Average life span once mature

1 month in you, 1 to 2 days in woman, 2 minutes on sheets

General Health and Lifestyle

A man’s general health and lifestyle may affect fertility. Some common causes of infertility related to health and lifestyle include:

Emotional stress. Stress may interfere with certain hormones needed to produce sperm. Your sperm count may be affected if you experience excessive or prolonged emotional stress. A problem with fertility itself can sometimes become long term and discouraging, producing more stress. Infertility can affect social relationships and sexual functioning.

Malnutrition. Deficiencies in nutrients such as vitamin C, selenium, zinc and folate may contribute to infertility.

Obesity. Increased body mass may be associated with fertility problems in men.

Cancer and its treatment. Both radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility. You may want to consider freezing (cryopreserving) your sperm before cancer treatment to ensure future fertility.

Alcohol and drugs. Alcohol or drug dependency can be associated with general ill health and reduced fertility. The use of certain drugs also can contribute to infertility. Anabolic steroids, for example, which are taken to stimulate muscle strength and growth, can cause the testicles to shrink and sperm production to decrease.

Other medical conditions. A severe injury or major surgery can affect male fertility. Certain diseases or conditions, such as diabetes, thyroid disease, HIV/AIDS, Cushing’s syndrome, anemia, heart attack, and liver or kidney failure, may be associated with infertility.

Age. A gradual decline in fertility is common in men older than 35.

Environmental Exposure

Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm count either directly by affecting testicular function or indirectly by altering the male hormonal system. Specific causes include:

Pesticides and other chemicals. Herbicides and insecticides may cause female hormone-like effects in the male body and may be associated with reduced sperm production. Exposure to such chemicals also may contribute to testicular cancer. Men exposed to hydrocarbons, such as ethylbenzene, benzene, toluene, xylen and aromatic solvents used in paint, varnishes, glues, metal degreasers and other products, may be at risk of infertility. Men with high exposure to lead also may be more at risk.

Testicular exposure to overheating. Frequent use of saunas or hot tubs can elevate your core body temperature. This may impair your sperm production and lower your sperm count.

Substance abuse. Cocaine or heavy marijuana use may temporarily reduce the number and quality of your sperm.

Tobacco smoking. Men who smoke may have a lower sperm count than do those who don’t smoke.

Overexposure to certain environmental elements such as heat, toxins and chemicals can reduce sperm count either directly by affecting testicular function or indirectly by altering the male hormonal system. Specific causes include:

Pesticides and other chemicals. Herbicides and insecticides may cause female hormone-like effects in the male body and may be associated with reduced sperm production. Exposure to such chemicals also may contribute to testicular cancer. Men exposed to hydrocarbons, such as ethylbenzene, benzene, toluene, xylen and aromatic solvents used in paint, varnishes, glues, metal degreasers and other products, may be at risk of infertility. Men with high exposure to lead also may be more at risk.

Testicular exposure to overheating. Frequent use of saunas or hot tubs can elevate your core body temperature. This may impair your sperm production and lower your sperm count.

Substance abuse. Cocaine or heavy marijuana use may temporarily reduce the number and quality of your sperm.

Tobacco smoking. Men who smoke may have a lower sperm count than do those who don’t smoke.

This condition usually results from inflammation of the fallopian tube (salpingitis). Chlamydia is the most frequent cause. Tubal inflammation may go unnoticed or cause pain and fever.

Tubal damage with scarring is the major risk factor of a pregnancy in which the fertilized egg is unable to make its way through the fallopian tube to implant in the uterus (ectopic pregnancy). One episode of tubal infection may cause fertility difficulties. The risk of ectopic pregnancy increases with each occurrence of tubal infection.

Endometriosis

Endometriosis occurs when the tissue that makes up the lining of the uterus grows outside of the uterus. This tissue most commonly is implanted on the ovaries or the lining of the abdomen near the uterus, fallopian tubes and ovaries. These implants respond to the hormonal cycle and grow, shed and bleed in sync with the lining of the uterus each month, which can lead to scarring and inflammation. Pelvic pain and infertility are common in women with endometriosis.

Infertility in endometriosis also may be due to:

Ovarian cysts (endometriomas). Ovarian cysts may indicate advanced endometriosis and often are associated with reduced fertility. Endometriomas can be treated with surgery.

Scar tissue. Endometriosis may cause rigid webs of scar tissue between the uterus, ovaries and fallopian tubes. This may prevent the transfer of the egg to the fallopian tube.

Ovulation Disorders

Some cases of female infertility are caused by ovulation disorders. Disruption in the part of the brain that regulates ovulation (hypothalamic-pituitary axis) can cause deficiencies in luteinizing hormone (LH) and follicle-stimulating hormone (FSH). Even slight irregularities in the hormone system can affect ovulation.

Specific causes of hypothalamic-pituitary disorders include:

Direct injury to the hypothalamus or pituitary gland

Pituitary tumors

Excessive exercise

Anorexia nervosa

Elevated Prolactin (Hyperprolactinemia)

The hormone prolactin stimulates breast milk production. High levels in women who aren’t pregnant or nursing may affect ovulation. An elevation in prolactin levels may also indicate the presence of a pituitary tumor. In addition, some drugs can elevate levels of prolactin. Milk flow not related to pregnancy or nursing (galactorrhea) can be a sign of high prolactin.

Polycystic Ovary Syndrome (PCOS)

An increase in androgen hormone production causes PCOS. In women with increased body mass, elevated androgen production may come from stimulation by higher levels of insulin. In lean women, the elevated levels of androgen may be stimulated by a higher ratio of luteinizing hormone (LH). Lack of menstruation (amenorrhea) or infrequent menses (oligomenorrhea) are common symptoms in women with PCOS.

In PCOS, increased androgen production prevents the follicles of the ovaries from producing a mature egg. Small follicles that start to grow but can’t mature to ovulation remain within the ovary. A persistent lack of ovulation may lead to mild enlargement of the ovaries.

Without ovulation, the hormone progesterone isn’t produced and estrogen levels remain constant. Elevated levels of androgen may cause increased dark or thick hair on the chin, upper lip or lower abdomen as well as acne and oily skin.

Early Menopause (Premature Ovarian Failure)

Early menopause is the absence of menstruation and the early depletion of ovarian follicles before age 35. Although the cause is often unknown, certain conditions are associated with early menopause, including:

Autoimmune disease. The body produces antibodies to attack its own tissue, in this case the ovary. This may be associated with hypothyroidism (too little thyroid hormone).

Radiation or chemotherapy for the treatment of cancer.

Tobacco smoking.

Benign Uterine Fibroids

Fibroids are benign tumors in the wall of the uterus and are common in women in their 30s. Occasionally they may cause infertility by interfering with the contour of the uterine cavity, blocking the fallopian tubes.

Pelvic Adhesions

Pelvic adhesions are bands of scar tissue that bind organs after pelvic infection, appendicitis, or abdominal or pelvic surgery. They may limit the functioning of the ovaries and fallopian tubes and impair fertility. Scar tissue formation inside the uterine cavity after a surgical procedure may result in a closed uterus and ceased menstruation (Asherman’s syndrome). This is most common following surgery to control uterine bleeding after giving birth.

Other Causes

A number of other causes can lead to infertility in women:

Medications. Temporary infertility may occur with the use of certain medications. In most cases, fertility is restored when the medication is stopped.

Thyroid problems. Disorders of the thyroid gland, either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism), can interrupt the menstrual cycle and cause infertility.

Cancer and its treatment. Certain cancers particularly female reproductive cancers — often severely impair female fertility. Both radiation and chemotherapy may affect a woman’s ability to reproduce. Chemotherapy may impair reproductive function and fertility more severely in men than in women.

Risk Factors

Many of the risk factors for both male and female infertility are the same. They include:

Age. Age is the strongest predictor of female fertility. After about age 32, a woman’s fertility potential gradually declines. A woman does not renew her oocytes (eggs). Infertility in older women may be due to a higher risk of chromosomal abnormalities that occur in the eggs as they age. Older women are also more likely to have health problems that may interfere with fertility. The risk of miscarriage also increases with a woman’s age. A gradual decline in fertility is possible in men older than 35.

Tobacco smoking. Women who smoke tobacco may reduce their chances of becoming pregnant and the possible benefit of fertility treatment. Miscarriages are more frequent in women who smoke.

Alcohol. There’s no certain level of safe alcohol use during conception or pregnancy.

Body mass. Extremes in body mass — either too high (body mass index, or BMI, of greater than 25.0) or too low (BMI of lower than 20.0) — may affect ovulation and increase the risk of infertility.

Being overweight. Among American women, infertility often is due to a sedentary lifestyle and being overweight.

Being underweight. Women at risk include those with eating disorders, such as anorexia nervosa or bulimia, and women following a very low-calorie or restrictive diet. Strict vegetarians also may experience infertility problems due to a lack of important nutrients such as vitamin B-12, zinc, iron and folic acid. Marathon runners, dancers and others who exercise very intensely are more prone to menstrual irregularities and infertility.

What’s Normal?

Most pregnancies occur during the first six cycles of intercourse in the fertile phase. Overall, after 12 months of unprotected intercourse, approximately 85 percent of couples will become pregnant. Over the next 36 months, about 50 percent of the remaining couples will go on to conceive spontaneously.

Conditions Affecting Both Partners

A number of factors that affect males and females alike can increase the risk of infertility. Perhaps the most common problem is age the older a person is, the more difficult it is to become pregnant. Over the last 20 to 30 years there has been a trend to delay childbearing, often until women are in their 30s. A woman reaches her peak fertility at age 18 or 19, with little change until the mid-20s. As she approaches age 30, her hormone levels start to decline and her fertility also begins a slow decline, with a more rapid decline after age 35. Menopause, which occurs in the late 40s to early 50s in most women, marks the end of a woman’s natural ability to bear children. A man’s fertility decline is not as rapid and has no clear-cut end point, but a man of 50 has lower hormone levels and is likely less fertile than he was at age 25 or 30.

What Are Infertility, Sub fertility, and Sterility?

Doctors use these and other terms to define different types of fertility-related conditions. Even so, the definitions of the above terms have changed as technology has advanced.

Sterility is the absolute inability to procreate. For instance, a woman has no uterus or a man has no testes (the male sex organs). In years past, a woman with blocked fallopian tubes or a man with an obstructed vas deferens would be considered sterile and beyond help. With the advent of assisted reproductive technology (ART), however, this is no longer the case. Many couples who were once in this category can now get help.

Infertility is usually defined as the inability to achieve pregnancy after one year of frequent, unprotected intercourse. This is not an exact measurement. Over time many couples in this category may, in fact, achieve pregnancy. Statisically, after five years, nearly one half of so-called “infertile” couples do conceive.

Subfertility is used to describe the gray area between normal fertility and sterility; the term is often used interchangeably with infertility.

Fecundability, from “fecunditas,” the Latin word for fertility, is the average pregnancy rate after one menstrual cycle. The normal rate in humans is 20%. Seventy-five percent of normally fertile couples are expected to have conceived in six months, and almost 100% by one year.

Normal fertility can be considered from the point of view of the couple, the female, or the male. We are going to look at male fertility its biological steps and mechanisms, defects, the causes of those defects and what can be done to remedy them.

Normal Male Fertility

As male factors have been increasingly implicated as a major cause of infertility, investigators have focused on the underlying physical processes in men. If the sperm count is low, then why? Or, if the sperm count is normal, why do the sperm not fertilize?

That there are literally dozens of factors leading to a completely normal spermatozoon, the form of sperm that is present in semen. These involve the structure of the testis; the hormones that influence its function; the receptors for these hormones; the maturation process through which the germ cell develops into a spermatozoon; the composition of the seminal plasma; and all the enzymes, receptors, and reactions that make the sperm capable of fertilizing the egg. In these steps, there are dozens of occasions for mistakes and problems.

Normal Female Fertility

Knowing your own body and being able to tell when you are fertile or ovulating is an important skill that every woman should have. You will save yourself an enormous amount of worry and anxiety when you get to know your body and can control your risk of unwanted pregnancy.

The fact is that there are only certain times during your menstrual cycle when you are fertile or can get pregnant in. So it pays off to know when those times are.

Your body will give you clear clues and signals as to when fertility is approaching and happening.

A woman is fertile when she is ovulating and for a few days before ovulation when fertile cervical mucus is present.

Ovulation usually occurs mid cycle. More precisely, ovulation usually occurs 14 days before the onset of bleeding.

Not at day 14 of the menstrual cycle as is commonly believed.

However – ovulation can be upset and delayed by many factors, eg, sickness, alcohol, travel, stress etc which is why simply counting the days can be inaccurate.

You will find your success in tracking your fertility will be far greater when you become adept at recognizing your own personal fertility signals rather than just counting the days.

Ovulation can also spontaneously occur during your natal lunar phase. Your natal lunar (moon) phase fertile time can occur at any time during your menstrual cycle, including before, during and after your period.

Your natal lunar fertile time is individual to you and is calculated from your birth data – it is all to do with which phase of the moon you were born under.

Male Infertility

Approximately 15% of couples attempting their first pregnancy meet with failure. Most authorities define these patients as primarily infertile if they have been unable to achieve a pregnancy after one year of unprotected intercourse. Conception normally is achieved within twelve months in 80-85% of couples who use no contraceptive measures, and persons presenting after this time should therefore be regarded as possibly infertile and should be evaluated. Data available over the past twenty years reveal that in approximately 30% of cases pathology is found in the man alone, and in another 20% both the man and woman are abnormal. Therefore, the male factor is at least partly responsible in about 50% of infertile couples.

Important issues related to the evaluation of the male factor include the most appropriate time for the male evaluation, the most efficient format for a comprehensive male exam, and definition of rationale and effective medical and surgical regimens in the treatment of these disorders. It is extremely important in the evaluation of infertility to consider the couple as a unit in evaluation and treatment and to proceed in a parallel investigative manner until a problem is uncovered. It has been shown that the longer a couple remains sub fertile, the worse their chance for an effective cure. Many couples experience significant apprehension and anxiety after only a few months of failure to conceive. Unduly prolonged unprotected intercourse should not be advocated before a workup of the man is instituted. Initial screening of the man should be considered whenever the patient presents with the chief complaint of infertility. This initial evaluation should be rapid, non-invasive and cost effective. Of interest is the fact that pregnancy rates of up to 50% have been reported when only the woman has been investigated and treated even when the man was found to have moderately severe abnormalities of semen quality.

Causes

Causes generally can be divided into pretesticular, testicular, and posttesticular.

Pretesticular Causes of Infertility

Pretesticular causes of infertility include congenital or acquired diseases of the hypothalamus, pituitary, or peripheral organs that alter the hypothalamic-pituitary axis.

Hypothalamus

Disorders of the hypothalamus lead to hypogonadotropic hypogonadism. If GnRH is not secreted, the pituitary does not release LH and FSH. Ideally, patients respond to replacement with exogenous GnRH or HCG, an LH analogue, although this does not always occur.

Idiopathic hypogonaotropic hypogonadism

A failure of GnRH secretion without any discernible underlying cause may be observed alone (isolated) or as part of Kallmann syndrome, which is associated with midline defects such as anosmia, cleft lip and cleft palate, deafness, cryptorchidism, and color blindness. Kallmann syndrome has been described in both familial (X-linked and autosomal) and sporadic forms, and its incidence is estimated as 1 case per 10,000-60,000 births.

A failure of GnRH neurons to migrate to the proper location in the hypothalamus has been implicated. Patients generally have long arms and legs due to a delayed closure of the epiphyseal plates, delayed puberty, and atrophic testis. Testosterone therapy may allow patients to achieve normal height but does not improve spermatogenesis. Exogenous testosterone should never be administered in an attempt to boost sperm production because it actually decreases intratesticular testosterone levels owing to feedback inhibition of GnRH release.

Pulsatile GnRH and HCG have been used but result in only 20% achieving complete spermatogenesis.

Adding recombinant human FSH to HCG has been shown to be effective in achieving spermatogenesis in most patients.

Prader-Willi syndrome: Patients have characteristic obesity, mental retardation, small hands and feet, and hypogonadotropic hypogonadism due to a GnRH deficiency. Prader-Willi syndrome is caused by a disorder of genomic imprinting with deletions of paternally derived chromosome arm 15q11-13.

Laurence-Moon-Biedl syndrome: Patients with this syndrome have retinitis pigmentosa and polydactyly. Infertility is due to hypogonadotropic hypogonadism.

Other conditions: Various other lesions and diseases, such as CNS tumors, temporal lobe seizures, and many drugs (eg, dopamine antagonists) may interrupt the hypothalamic-pituitary axis at the hypothalamus.

Pituitary

Both pituitary insufficiency and pituitary excess cause infertility. Pituitary failure may be congenital or acquired. Acquired causes include tumor, infarction, radiation, infection, or granulomatous disease. Nonfunctional pituitary tumors may compress the pituitary stalk or the gonadotropic cells, interrupting the proper chain of signals leading to pituitary failure. In contrast, functional pituitary tumors may lead to unregulated gonadotropin release or prolactin excess, interrupting the proper signaling.

Prolactinoma

A prolactin-secreting adenoma is the most common functional pituitary tumor. Prolactin stimulates breast development and lactation; therefore, patients with infertility due to a prolactinoma may have gynecomastia and galactorrhea. In addition, loss of peripheral visual fields bilaterally may be due to compression of the optic chiasm by the growing pituitary tumor.

A prolactin level of more than 150 mcg/L suggests a pituitary adenoma, while levels greater than 300 mcg/L are nearly diagnostic. Patients should undergo an MRI or CT scan of the sella turcica for diagnostic purposes to determine whether a microprolactinoma or a macroprolactinoma is present.

Bromocriptine, a dopamine agonist, is used to suppress prolactin levels and is the therapy of choice for microprolactinomas. Cabergoline is also a treatment option. Some men respond with an increase in testosterone levels; many also recover normal sperm counts. Transsphenoidal resection of a microprolactinoma is 80-90% successful, but as many as 17% recur. Surgical therapy of a macroprolactinoma is rarely curative, although this should be considered in patients with visual-field defects or those who do not tolerate bromocriptine.

Isolated LH deficiency (fertile eunuch): In these patients, LH levels are decreased while FSH levels are within the reference range. Patients have eunuchoidal body habitus, large testis, and a low ejaculatory volume. The treatment of choice is exogenous HCG.

Isolated FSH deficiency: This is a very rare cause of infertility. Patients present with oligospermia but have LH levels within the reference range. Treatment is with human menopausal gonadotropin (HMG) or exogenous FSH.

Thalassemia: Patients with thalassemia have ineffective erythropoiesis and undergo multiple blood transfusions. Excess iron from multiple transfusions may get deposited in the pituitary gland and the testis, causing parenchymal damage and both pituitary and testicular insufficiency. Treatment is with exogenous gonadotropins and iron-chelating therapy.

The hypothalamus-pituitary axis may be interrupted by hormonally active peripheral tumors or other exogenous factors, due to cortical excess, cortical deficiency, or estrogen excess.

Excess cortisol may be produced by adrenal hyperplasia, adenomas, carcinoma, or lung tumors. High cortisol levels may also be seen with exogenous steroid use, such as that administered to patients with ulcerative colitis, asthma, arthritis, or organ transplant. For example, high cortisol levels are seen in patients with Cushing syndrome, which causes negative feedback on the pituitary to decrease LH release.

Cortical deficiency may be seen in patients with adrenal failure due to infection, infarction, or congenital adrenal hyperplasia (CAH). CAH may be due to the congenital deficiency of one of several adrenal enzymes, the most common of which is 21-hydroxylase deficiency. Because cortisol is not secreted, a lack of feedback inhibition on the pituitary gland occurs, leading to adrenocorticotropic hormone (ACTH) hypersecretion. This leads to increased androgen secretion from the adrenal gland, causing feedback inhibition of GnRH release from the hypothalamus. Patients present with short stature, precocious puberty, small testis, and occasional bilateral testicular rests. Screening tests include increased plasma 17-hydroxylase and urine 17-ketosteroids.

Primary Testicular Causes of Infertility

Primary testicular problems may be chromosomal or non chromosomal in nature. While chromosomal failure is usually caused by abnormalities of the sex chromosomes, autosomal disorders are also observed.

Chromosomal Abnormalities

An estimated 6-13% of infertile men have chromosomal abnormalities (compared with 0.6% of the general population). Patients with azoospermia or severe oligospermia are more likely to have a chromosomal abnormality (10-15%) than infertile men with sperm density within the reference range (1%). A karyotype test and a Y chromosome test for microdeletions are indicated in patients with nonobstructive azoospermia or severe oligospermia (<5 million sperm/mL), although indications are expanding.

Klinefelter syndrome is the most common chromosomal cause of male infertility, estimated to be present in 1 per 500-1000 male births. Classic Klinefelter syndrome has a 47, XXY karyotype and is caused by a nondisjunction during the first meiotic division, more commonly of maternal origin; mosaic forms are due to nondisjunction following fertilization. The only known risk factor for Klinefelter syndrome is advanced maternal age. Infertility is caused by primary testicular failure, and most patients are azoospermic. Hormonal analysis reveals increased gonadotropin levels, while 60% have decreased testosterone levels. Surprisingly, most patients have normal libido, erections, and orgasms, so testosterone therapy has only a limited role; exogenous testosterone may also suppress any underlying sperm production.

Physical examination reveals gynecomastia, small testis, and eunuchoid body habitus due to delayed puberty. In some patients, secondary sex characteristics develop normally, but they are usually completed late. These men are at a higher risk for breast cancer, leukemia, diabetes, empty sella syndrome, and pituitary tumors. Testicular histology reveals hyalinization of seminiferous tubules. Some men with Klinefelter syndrome may be able to conceive with the help of assisted reproductive techniques. Of azoospermic patients with Klinefelter syndrome, 20% show the presence of residual foci of spermatogenesis. Although the XXY pattern is observed in the spermatogonia and primary spermatocytes, many of the secondary spermatocytes and spermatids have normal patterns. The chromosomal pattern of the resultant embryos can be assessed with preimplantation genetic diagnosis.

XX male (sex reversal syndrome): An XX karyotype is due to a crossover of the sex-determining region (SRY) of the Y chromosome (with the testis determining factor) to either the X chromosome or an autosome. Patients are often short, with small firm testis and gynecomastia, but they have a normal-sized penis. Seminiferous tubules show sclerosis.

XYY male: An XYY karyotype is observed in 0.1-0.4% of newborn males. These patients are often tall and severely oligospermic or azoospermic. This pattern has been linked with aggressive behavior. Biopsy reveals maturation arrest or germ cell aplasia. Functional sperm that are present may have a normal karyotype.

Noonan syndrome (46, XY): Patients with Noonan syndrome, also known as male Turner syndrome, have physical characteristics similar to that of women with Turner syndrome (45, X). Features include a webbed neck, short stature, low-set ears, ptosis, shield-like chest, lymphedema of hands and feet, cardiovascular abnormalities, and cubitus valgus. Leydig cell function is impaired, and most patients are infertile due to primary testicular failure.

Mixed gonadal dysgenesis (45, X/46, XY): Patients have ambiguous genitalia, a testis on one side, and a streaked gonad on the other.

Y chromosome microdeletion syndrome: The long arm of the Y chromosome (Yq) is considered critical for fertility, especially Yq11.23 (interval 6). Macroscopic deletions of Yq11 are often observed in patients with azoospermia, although many new microdeletions have been implicated as a significant cause of infertility. These microdeletions are not observed on regular karyotype; rather, their identification requires polymerase chain reaction (PCR)–based sequence-tagged site mapping or Southern blot analysis. Three regions have been described, called azoospermic factors a, b, and c (AZFa, AZFb, AZFc). These deletions are observed in 3-19% of patients with idiopathic infertility and 6-14% of patients with oligospermia, although up to 7% of patients with other known causes of infertility may also be found to have a deletion. Patients with azoospermia or severe oligospermia seeking assisted reproductive techniques should be screened.

Bilateral anorchia (vanishing testis syndrome): Patients have a normal male karyotype (46, XY) but are born without testis bilaterally. The male phenotype proves that androgen was present in utero. Potential causes are unknown, but it may be related to infection, vascular disease, or bilateral testicular torsion. Karyotype shows a normal SRY gene. Patients may achieve normal virilization and adult phenotype by the administration of exogenous testosterone, but they are infertile.

Down syndrome: These patients have mild testicular dysfunction with varying degrees of reduction in germ cell number. LH and FSH levels are usually elevated.

Myotonic dystrophy: This is an autosomal dominant defect in the dystrophin gene that causes a delay in muscle relaxation after contraction. Seventy-five percent of patients have testicular atrophy and primary testicular failure due to degeneration of the seminiferous tubules. Leydig cells are normal. Histology reveals severe tubular sclerosis. No effective therapy exists.

Nonchromosomal Testicular Failure

Testicular failure that is nonchromosomal in origin may be idiopathic or acquired by gonadotoxic drugs, radiation, orchitis, trauma, or torsion.

Varicoceles

A varicocele is a dilation of the veins of the pampiniform plexus of the scrotum. Although varicoceles are present in 15% of the male population, a varicocele is considered the most common correctable cause of infertility (30-35%) and the most common cause of secondary (acquired) infertility (75-85%). Varicoceles are observed more commonly on the left side than the right. Those with isolated right-sided varicoceles should be evaluated for retroperitoneal pathology.

Varicoceles are generally asymptomatic, and most men with varicoceles do not have infertility or testicular atrophy. However, varicoceles may lead to impaired testicular spermatogenesis and steroidogenesis, potentially due to an increased intratesticular temperature, reflux of toxic metabolites, and/or germ cell hypoxia as potential causes of these changes, and this appears to be progressive over time.

Varicoceles lead to an increased incidence of sperm immaturity, apoptosis, and necrosis with severe disturbances in meiotic segregation compared to fertile men without varicoceles, and these parameters generally improve after repair.

Patients with a grade 2-3 varicocele (visible or palpable) associated with infertility should have the varicocele repaired. After repair, 40-70% of patients have improved semen parameters, while 40% are able to achieve a pregnancy without other interventions. Those with a varicocele diagnosable only on scrotal ultrasonography will likely not benefit from repair. Adolescents with a varicocele and testicular atrophy or lack of growth should similarly undergo repair. Controversy exists regarding whether to routinely repair an adolescent varicocele not associated with testicular atrophy.

In those with azoospermia and a varicocele, sperm may appear after repair in up to one third, but most of these men return to an azoospermic state within a few months. If sperm appears, these men should be offered cryopreservation.

Cryptorchidism

An estimated 3% of full-term males are born with an undescended testicle, but fewer than 1% remain undescended by age 1 year. Undescended testicle may be isolated or may be observed as part of a syndrome such as prune belly syndrome. Patients are at increased risk of infertility, even if the testicle is brought down into the scrotum, as the testicle itself may be inherently abnormal. The farther from the scrotum, and the longer duration that the testicle resides outside the scrotum, the greater the likelihood of infertility. Testicular histology typically reveals a decreased number of Leydig cells and decreased spermatogenesis. Cryptorchidism may be due to inherent defects in both testes because even men with unilateral cryptorchidism have lower than expected sperm counts.

Trauma: Testicular trauma is the second most common acquired cause of infertility. The testes are at risk for both thermal and physical trauma because of their exposed position.

Sertoli cells-only syndrome (germinal cell aplasia): Patients with germinal cell aplasia have LH and testosterone levels within the reference range but have an increased FSH level. The etiology is unknown but is probably multifactorial. Patients have with small- to normal-sized testes and azoospermia, but normal secondary sex characteristics. Histology reveals seminiferous tubules lined by Sertoli cells and a normal interstitium, although no germ cells are present.

Chemotherapy: Chemotherapy is toxic to actively dividing cells. In the testicle, germ cells (especially up to the preleptotene stage) are especially at risk. The agents most often associated with infertility are the alkylating agents such as cyclophosphamide. For example, treatment for Hodgkin disease has been estimated to lead to infertility in as many as 80-100% of patients.

Radiation therapy: While Leydig cells are relatively radioresistant because of their low rate of cell division, the Sertoli and germ cells are extremely radiosensitive. If stem cells remain viable after radiation therapy, patients may regain fertility within several years. However, some have suggested that patients should avoid conception for 6 months to 2 years after completion of radiation therapy because of the possibility of chromosomal aberrations in their sperm caused by the mutagenic properties of radiation therapy. Even with the testis shielded, radiation therapy below the diaphragm may lead to infertility due to the release of reactive oxygen free radicals.

Orchitis

The most common cause of acquired testicular failure in adults is viral orchitis, such as that caused by the mumps virus, echovirus, or group B arbovirus. Of adults with who are infected with mumps, 25% develop orchitis; two thirds of cases are unilateral, and one third are bilateral. While orchitis develops a few days after the onset of parotid gland inflammation, it may also precede it. The virus may either directly damage the seminiferous tubules or indirectly cause ischemic damage as the intense swelling leads to compression against the tough tunica albuginea. After recovery, the testicle may return to normal or may atrophy. Atrophy is observed within 1-6 months, and the degree of atrophy does not correlate with the severity of orchitis or infertility. Normal fertility is observed in three fourths of patients with unilateral mumps orchitis and in one third of patients in bilateral orchitis.

Granulomatous disease: Leprosy and sarcoidosis may infiltrate the testicle and lead to testicular failure.

Sickle cell disease: Sickling of cells within the testis leads to microinfarcts and secondary testicular failure.

Excessive use of alcohol, cigarettes, caffeine, and marijuana may lead to testicular failure.

Idiopathic causes: Despite a thorough workup, nearly 25% of men have no discernible cause for their infertility.

Posttesticular Causes of Infertility

Posttesticular causes of infertility include problems with sperm transportation through the ductal system, either congenital or acquired. Genital duct obstruction is a potentially curable cause of infertility and is observed in 7% of infertile patients. Additionally, the sperm may be unable to cross the cervical mucus or may have ultra-structural abnormalities.

Congenital blockage of the ductal system: An increased rate of duct obstruction is observed in children of mothers who were exposed to DES during pregnancy. Segmental dysplasia is defined as a vas deferens with at least 2 distinct sites of vasal obstruction.

Cystic fibrosis: CF is the most common genetic disorder in whites. Patients with CF nearly uniformly have CBAVD. The cystic fibrosis transmembrane regulator (CFTR) protein plays a role in mesonephric duct development during early fetal life, so these patients may also have urinary tract abnormalities. Patients may be candidates for assisted reproduction techniques after appropriate genetic screening in the partner.

Acquired blockage of the ductal system: Genital ducts may become obstructed secondary to infections, such as chlamydia, gonorrhea, tuberculosis, and smallpox. Young syndrome is a condition that leads to inspissation of material and subsequent blockage of the epididymis. Trauma, previous attempts at sperm aspiration, and inguinal surgery may also result in ductal blockage. Small calculi may block the ejaculatory ducts, or prostatic cysts may extrinsically block the ducts. Scrotal surgery, including vasectomy, hydrocelectomy (5-6%), and spermatocelectomy (up to 17%), may lead to epididymal injury and subsequent obstruction.

Antisperm antibodies: Antisperm antibodies bind to sperm, impair motility, and lead to clumping, impairing movement through the female reproductive tract and interaction with the oocyte.

Immotile cilia syndrome may be isolated or part of Kartagener syndrome with situs inversus. Because of a defect in the dynein arms, spokes, or microtubule doublet, cilia in the respiratory tract and in sperm do not function properly. In addition to sperm immobility, patients experience sinusitis, bronchiectasis, and respiratory infections.

Ejaculatory duct obstruction: Complete and partial ejaculatory duct obstruction has been implicated as a cause of 1-5% of patients with male infertility. Patients may have a normal palpable vas deferens bilaterally but show decreased ejaculate volume and hemospermia and may experience pain upon ejaculation. Etiologies include cysts (midline and eccentric), ductal calcification and stones, postinfectious, and postoperative. Transrectal ultrasonography (TRUS) may reveal enlarged seminal vesicles, but this is not universal. Seminal vesicle aspiration revealing numerous sperm or a dynamic test such as injection of indigo carmine into the seminal vesicle or ejaculatory duct may be necessary for diagnosis.

Anejaculation/retrograde ejaculation may be due to an open bladder neck or a lack of rhythmic contractions during ejaculation. Etiologies include diabetic neuropathy, bladder neck surgery, RPLND, transurethral prostatectomy, colon or rectal surgery, multiple sclerosis, spinal cord injury, or the use of medicines such as alpha-antagonists. Diagnosis is suggested by history, a low ejaculate volume, and the observance of 10-15 sperm per high-power field (HPF) in the postejaculatory urine.

Physical Symptoms of Male Infertility

For men, the most typical symptom of male infertility that may signal an underlying fertility problem is six months of unprotected intercourse without successful conception. Unlike many cases of female infertility, most men do not show any physical symptoms of infertility problems, but continue to have trouble getting pregnant with their partner. Nonetheless, there are some infertility symptoms that may be experienced along with difficulty getting pregnant as a result of a specific, underlying cause of infertility.

Risk Factors

A number of risk factors are linked to male infertility. They include:

Don’t drink too much alcohol. Heavy drinking can impair fertility and sexual function. Drink no more than two drinks a day.

If you smoke tobacco, quit. Smoking is linked to impaired fertility.

Avoid exposure to heat. Steer clear of extended or regular use of hot tubs, saunas and steam baths. High temperatures are thought to temporarily impair sperm production.

Tests and Diagnosis

If you and your partner are unable to become pregnant within a reasonable time, see your doctor. Some infertile couples have more than one cause of their infertility. Your doctor will usually begin a comprehensive infertility examination on both you and your partner.

In some cases, the cause of your infertility may be unclear, or it may take a number of tests to determine the cause. Infertility tests can be expensive and may not be covered by insurance — find out what your medical plan covers ahead of time.

For a man to be fertile, the testicles must produce enough healthy sperm, and the sperm must be ejaculated effectively into the woman’s vagina. Tests for male infertility attempt to determine whether any of these processes are impaired.

General Physical Examination and Medical History

This includes examination of your genitals and questions about illnesses, disabilities and surgeries that could affect fertility. Your doctor will want to know what medications you take and your sexual habits. Your doctor may also ask about your sexual development as a boy and whether you’ve had any signs of low testosterone, such as decreased body or facial hair.

Semen Analysis

This is the most important test for the male partner. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A laboratory analyzes the physical characteristics of your semen, the number of sperm present and looks for any abnormalities in the shape and structure (morphology) and movement (motility) of the sperm. The lab will also check your semen for signs of problems, such as infections or blood. Often sperm counts fluctuate from one specimen to the next, so your doctor may want to evaluate a few different samples. If your sperm analysis is normal, your doctor will likely recommend thorough testing of your female partner before conducting further male infertility tests.

Depending on initial findings, your doctor may recommend additional, more specialized tests that can help identify the cause of your infertility. These can include:

Scrotal Ultrasound

Ultrasound, which uses high-frequency sound waves to produce images of structures within your body, can help your doctor look for evidence of a varicocele or obstruction of the epididymis.

Hormone Testing

Hormones produced by the pituitary and hypothalamus glands and the testicles play a key role in sexual development and sperm production. Your doctor may recommend a blood test to determine the level of testosterone and other male hormones that affect fertility. A number of infertility problems can be caused by an underlying condition that affects hormone levels.

Genetic Tests

These tests are used if your doctor suspects your fertility problems could be caused by an inherited sex chromosome abnormality. When sperm concentration is extremely low, genetic causes could be involved. A blood test can reveal whether there are subtle changes in the Y chromosome.

Testicular Biopsy

This test involves removing samples from the testicle with a needle. It may be used if your semen analysis shows no sperm at all. The results of the testicular biopsy will tell if sperm production is normal. If it is, your problem is likely caused by blockage or another problem with sperm transport.

Anti-Sperm Antibody Tests

These tests are used to check for immune cells (antibodies) that attack sperm and can affect their ability to function. You are especially likely to have anti-sperm antibodies if you’ve had vasectomy reversal.

Vasography

In some cases, contrast dye is injected into each vas deferens to see whether they are blocked.

Specialized Sperm Function Tests

A number of different tests can be used to evaluate how well your sperm survive after ejaculation, how well they can penetrate the egg membrane, and whether there’s any problem attaching to the egg.

Treatment

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The Causes of Male Infertility

Male infertility has many causes–from hormonal imbalances, to physical problems, to psychological and/or behavioral problems. Moreover, fertility reflects a man’s “overall” health. Men who live a healthy lifestyle are more likely to produce healthy sperm.

The following list highlights some lifestyle choices that negatively impact male fertility–it is not all-inclusive:

Exposure to environmental hazards and toxins such as pesticides, lead, paint, radiation, radioactive

substances, mercury, benzene, boron, and heavy metals

Malnutrition and anemia.

Excessive stress!

Modifying these behaviors can improve a man’s fertility and should be considered when a couple is trying to achieve pregnancy.

Hormonal Problems

A small percentage of male infertility is caused by hormonal problems. The hypothalamus-pituitary endocrine system regulates the chain of hormonal events that enables testes to produce and effectively disseminate sperm. Several things can go wrong with the hypothalamus-pituitary endocrine system:

The brain can fail to release gonadotrophic-releasing hormone (GnRH) properly. GnRH stimulates the hormonal pathway that causes testosterone synthesis and sperm production. A disruption in

GnRH release leads to a lack of testosterone and a cessation in sperm production.

(FSH) to stimulate the testes and testosterone/sperm production. LH and FSH are intermediates in the hormonal pathway responsible for testosterone and sperm production.

The testes’ Leydig cells may not produce testosterone in response to LH stimulation.

A male may produce other hormones and chemical compounds which interfere with the sex-hormone balance.

The following is a list of hormonal disorders which can disrupt male infertility:

Hyperprolactinemia

Elevated prolactin–a hormone associated with nursing mothers, is found in 10 to 40 percent of infertile males.

Mild elevation of prolactin levels produces no symptoms, but greater elevations of the hormone reduces sperm production, reduces libido and may cause impotence. This condition responds well to the drug Parlodel (bromocriptine).

Hypothyroidism

Low thyroid hormone levels–can cause poor semen quality, poor testicular function and may disturb libido. May be caused by a diet high in iodine.

Reducing iodine intake or beginning thyroid hormone replacement therapy can elevate sperm count. This condition is found in only 1 percent of infertile men.

Congenital Adrenal Hyperplasia

Occurs when the pituitary is suppressed by increased levels of adrenal androgens. Symptoms include low sperm count, an increased number of immature sperm cells, and low sperm cell motility. Is treated with cortisone replacement therapy. This condition is found in only 1 percent of infertile men.

Hypogonadotropic Hypopituitarism

Low pituitary gland output of LH and FSH. This condition arrests sperm development and causes the progressive loss of germ cells from the testes and causes the seminiferous tubules and Leydig (testosterone producing) cells to deteriorate.

May be treated with the drug Serophene. However, if all germ cells are destroyed before treatment commences, the male may be permanently infertile.

Physical Problems

A variety of physical problems can cause male infertility. These problems either interfere with the sperm production process or disrupt the pathway down which sperm travel from the testes to the tip of the penis. These problems are usually characterized by a low sperm count and/or abnormal sperm morphology. The following is a list of the most common physical problems that cause male infertility.

Azoospermia

Azoospermia is the complete absence of sperm in the semen and as such means that a man will be completely infertile.

The diagnosis of azoospermia is sometimes still made even though as many as 500,000 sperm per ml of semen may have been seen because it is extremely unlikely that the man will be able to father a child naturally with this number of sperm. Its incredible to realise that millions are needed for any chance of natural conception!

However, modern techniques such as ICSI (intra cytoplasmic sperm injection) mean that a man can still father his own biological child with expert medical help – This means that you must ask your doctor whether you have either (i) a very low sperm count so that you know you do at least make some sperm or (ii) absolutely no sperm at all which is the worst case scenario for any man to face.

In fact it is rare that a man has absolutely no sperm at all and as long as some sperm are produced it is possible nowadays to help couples have children via the ICSI procedure. So, if the doctor says you have azoospermia make sure you ask for a copy of the semen analysis results so that you can understand the situation.

Azoospermia occurs in about 2% of men in the general population. So whilst not common there are plenty of infertile men around – in the UK alone we would expect to find at least 300,000 men with azoospermia and many of these would appear extremely healthy and have no indication that any problem might exist !

Around 10-20% of men attending infertility centers will probably have azoospermia as well. This means that if you and your partner have been trying for a year or more to have a baby there is an increased risk that you may have a problem.

Oligospermia

Oligospermia is the leading cause of male fertility problems. A normal sperm count is 20 million or more per millimetre of semen. In order for conception to occur, a minimum of 60% of these sperm should have a normal shape (morphology) and normal forward movement (motility).

However, the above sperm count figure represents a general guideline, as some men with a higher sperm count have had difficulty conceiving while men with a sperm count lower than this number have been able to successfully get their partners pregnant.

Necrospermia

Necrospermia is a condition in which sperm are produced and found in the semen but are not alive and are unable to fertilize eggs. That over 40% sperms are dead in the semen analysis indicates necrospermia.

Necrospermia is a condition in which sperm are produced and found in the semen but are not alive and are unable to fertilize eggs. That over 40% sperms are dead in the semen analysis indicates necrospermia.

Necrospermia is still a poorly documented cause of male infertility. Among infertile subjects, the incidence reported in the literature is 0.2 to 0.48 per cent. We undertook a retrospective study to contribute to the comprehension of this abnormality. Histories, physical examination, analysis of the semen and hormonal dosages performed in necrozoospermic subjects were reviewed. We observed that in patients with necrospermia in at least three semen samples, infections represent 40 per cent of aetiologies. In 20% of the whole population, no aetiology was observed, but abnormalities of the epididymis function were suggested. Through this study, we suggest an aetiological classification and practical guidance in case of necrozoospermia.

Antisperm Antibodies

Necrospermia is still a poorly documented cause of male infertility. Among infertile subjects, the incidence reported in the literature is 0.2 to 0.48 per cent. We undertook a retrospective study to contribute to the comprehension of this abnormality. Histories, physical examination, analysis of the semen and hormonal dosages performed in necrozoospermic subjects were reviewed.

We observed that in patients with necrospermia in at least three semen samples, infections represent 40 per cent of aetiologies. In 20% of the whole population, no aetiology was observed, but abnormalities of the epididymis function were suggested. Through this study, we suggest an aetiological classification and practical guidance in case of necrozoospermia.

Semen

This condition may be treated by several methods such as cortisone, sperm washing which increases sperm concentration, intrauterine insemination, or in vitro fertilization. Semen volume – the amount of fluid that makes up the semen

Sperm count – the number of sperm present in a standard volume. A normal sample contains more than 20 million sperm per milliliter.

Motility – the percent of sperm moving when the semen is examined under the microscope. Normal is defined as >50% motile.

Progression – the forward movement of sperm cells

Viability – the percent of live sperm

Sperm morphology or shape

Additional semen contents, such as white blood cells, are an indication of infection. Less than five white blood cells per high power field is considered normal.

Semen

Average volume of ejaculate

0.5 to 1 teaspoon

Chief ingredient

Fructose sugar

Caloric content

5 calories per teaspoon

Protein content

6 milligrams per teaspoon

Average number of ejaculatory spurts

3 to 10

Average interval of ejaculatory contractions

0.8 seconds

Farthest medically recorded ejaculation

11.7 inches

Variocoele

A varicocele is an enlargement of the internal spermatic veins that drain blood from the testicle to the abdomen (back to the heart) and are present in 15% of the general male population and 40% of infertile men. These images show what a variocoele looks like externally and internally.

A varicocele develops when the one way valves in these spermatic veins are damaged causing an abnormal back flow of blood from the abdomen into the scrotum creating a hostile environment for sperm development. Varicocoeles may cause reduced sperm count and abnormal sperm morphology which cause infertility. Variococles can usually be diagnosed by a physical examination of the scrotum which can be aided by the Doppler stethoscope and scrotal ultrasound. Varicocoele can be treated in many ways (see treatment section), but the most successful treatments involve corrective surgery.

Damaged Sperm Ducts

Seven percent of infertile men cannot transport sperm from their testicles to out of their penis.

This pathway may be blocked by a number of conditions:

A genetic or developmental mistake may block or cause the absence of one or both tubes (which transport the sperm from the testes to the penis).

Scarring from tuberculosis or some STDs may block the epididymis or tubes.

An elective or accidental vasectomy may interrupt tube continuity.

Torsion

Is a common problem affecting fertility that is caused by a supportive tissue abnormality which allows the testes to twist inside the scrotum which is characterized by extreme swelling.

Torsion pinches the blood vessels that feed the testes shut which causes testicular damage. If emergency surgery is not performed to untwist the testes, torsion can seriously impair fertility and cause permanent infertility if both testes twist.

Infection and Disease

Mumps, tuberculosis, brucellosis, gonorrhea, typhoid, influenza, smallpox, and syphilis can cause testicular atrophy. A low sperm count and low sperm motility are indicators of this condition. Also, elevated FSH levels and other hormonal problems are indicative of testicular damage. Some STDs like gonorrhea and chlamydia can cause infertility by blocking the epididimis or tubes. These conditions are usually treated by hormonal replacement therapy and surgery in the case of tubular blockage.

Testicular Failure

This generally refers to the inability of the sperm-producing part of the testicles (the seminiferous elithelium) to make adequate numbers of mature sperm. This failure may occur at any stage in sperm production for a number of reasons. The testicle may completely lack the cells that divide to become sperm (Sertoli Cell-Only Syndrome). There may be an inability of the sperm to complete their development (maturation arrest). Sperm may be made in such low numbers that few, if any, successfully travel through the ducts and into the ejaculated fluid (hypospermatogeneses). This situation may be caused by genetic abnormalities, hormonal factors, or varicoceles.

Even in the case where the testes are only producing low numbers of sperm, the sperm may be harvested and used in conjunction with advanced reproductive techniques to attempt a pregnancy.

Cryptorchidism

Cryptochiridism may be a cause of testicular failure. When a baby boy is born without the testes having fully descended into the scrotum, the condition is known as cryptorchidism.

Since the testes are very sensitive to temperature, if they do not descend into the scrotum prior to adolescence, they will stop producing sperm altogether. In fact, they have a higher rate of malignancy. The current recommendation is that at approximately one year of age, if the testes have not descended by themselves, they be brought down surgically.

Cryptorchidism is often associated with male factor infertility. Eight-one percent of men who have a single testis that is cryptorchid have normal fertility. However, approximately, 50% of men who have bilateral cryptorchidism have normal fertility. This may be due both to something inherent in the testes, to the surgery, or to damage done by not having the testes brought down in time.

Mumps

Mumps is the best-known cause, but is not the only one. Mumps will only affect fertility if it causes orchitis and, even then, only rarely. Undescended testicles (cryptorchidism) are another common cause of failure of sperm production. Male infants and children are routinely examined to identify this problem, as future fertility can only be preserved if surgical treatment to fix the testicles in the scrotum is performed in early childhood. Even surgery in infancy does not guarantee future fertility.

Orchitis

Orchitis is an inflammation of testicle tissue. Mumps orchitis, a complication of the childhood viral disease, is the most typical example of complication in childhood;

however, some men who get mumps with swelling of the parotid gland (the saliva-producing glands in the cheeks) will experience an inflammation in one or sometimes both testicles.

Klinefelter’s Syndrome

Is a genetic condition in which each cell in the human body has an additional X chromosome–men with Klinefelter’s Syndrome have one Y and two X chromosomes. Physical symptoms include peanut-sized testicles and enlarged breasts. A chromosome analysis is used to confirm this analysis. If this condition is treated in its early stages (with the drug hCG), sperm production may commence and/or improve. However, Klinefelter’s Syndrome eventually causes all active testicular structures to atrophy. Once testicular failure has occurred, improving fertility is impossible.

Retrograde Ejaculation

Is a condition in which semen is ejaculated into the bladder rather than out through the urethra because the bladder sphincter does not close during ejaculation.

If this disorder is present, ejaculate volume is small and urine may be cloudy after ejaculation. This condition affects 1.5 percent of infertile men and may be controlled by medications like decongestants which contract the bladder sphincter or surgical reconstruction of the bladder neck can restore normal ejaculation.

Psychological/Physical/Behavioral Problems

Several sexual problems exist that can affect male fertility. These problems are most often both psychological and physical in nature: it is difficult to separate the physiological and physical components.

Erectile Disfunction (ED)

Also known as impotence, this condition is common and affects 20 million American men. ED is the result of a single, or more commonly a combination of multiple factors. In the past, ED was thought to be the result of psychological problems, but new research indicates that 90 percent of cases are organic in nature. However, most men who suffer from ED have a secondary psychological problem that can worsen the situation like performance anxiety, guilt, and low self-esteem. Many of the common causes of impotence include: diabetes, high blood pressure, heart and vascular disease, stress, hormone problems, pelvic surgery, trauma, venous leak, and the side effects of frequently prescribed medications (i.e. Prozac and other SSRIs, Propecia). Luckily, many treatment options exist for ED depending on the cause–these will be discussed in the treatment section.

Premature Ejaculation

Is defined as an inability to control the ejaculatory response for at least thirty seconds following penetration. Premature ejaculation becomes a fertility problem when ejaculation occurs before a man is able to fully insert his penis into his partner’s vagina. Premature ejaculation can be overcome by artificial insemination or by using a behavioral modification technique called the “squeeze technique” which desensitizes the penis.

Ejaculatory Incompetence

This rare psychological condition prevents men from ejaculating during sexual intercourse even though they can ejaculate normally through masturbation. This condition sometimes responds well to behavioral therapy; if this technique does not work, artificial insemination can be employed using an ejaculate from masturbation.

General Medical Disorders that Reduce Fertility

There are several conditions that may reduce fertility

FeverInfluenza (flu), pneumonia, or even a severe cold can cause a high fever, which will adversely affect sperm production and quality. These changes usually recover over a few weeks.

DiabetesIn the longer term, diabetes can cause problems with erection and ejaculation through causing damage to the function of the ‘automatic nervous system’.

High Blood PressureHypertension (high blood pressure) can cause problems with erection, either directly or as a side effect of medication.

Coronary Artery DiseaseCoronary artery disease can cause problems with erection. This could be due to generalised hardening of the arteries, in the penis as well as the heart, or to drugs used in the treatment of heart problems.

Neurological DisordersMultiple sclerosis, stroke, and spinal cord injury and disease can all cause problems with erection and ejaculation.

Kidney DiseaseChronic renal failure, which results in a build up of waste products in the body, can adversely affect sperm quality and fertility. It can also cause erection problems.

CancersThat affect the genital tract or endocrine (hormone-producing) systems may directly reduce fertility. Otherwise, drugs and radiation used to treat cancer may severely reduce sperm production or even stop it altogether. Stress (see below) may also have an effect.

AlcoholismAlcohol is toxic to sperm and overuse of alcohol can reduce sperm quality and fertility.

StressStress causes several hormonal changes in the body that can affect fertility. Stress can have many causes, including anxiety over fertility problems.

General Health and LifestyleA man’s general health and lifestyle may affect fertility. Some common causes of infertility related to health and lifestyle include:

Emotional StressStress may interfere with certain hormones needed to produce sperm. Your sperm count may be affected if you experience excessive or prolonged emotional stress. A problem with fertility itself can sometimes become long term and discouraging, producing more stress. Infertility can affect social relationships and sexual functioning.

MalnutritionDeficiencies in nutrients such as vitamin C, selenium, zinc and folate may contribute to infertility.

ObesityIncreased body mass may be associated with fertility problems in men.

Cancer and its TreatmentBoth radiation and chemotherapy treatment for cancer can impair sperm production, sometimes severely. The closer radiation treatment is to the testicles, the higher the risk of infertility. Removal of one or both testicles due to cancer also may affect male fertility.

Pesticides and other ChemicalsHerbicides and insecticides may cause female hormone-like effects in the male body and may be associated with reduced sperm production and testicular cancer. Lead exposure may also cause infertility.

Substance AbuseUse of cocaine or marijuana may temporarily reduce the number and quality of your sperm.

Other Medical ConditionsA severe injury or major surgery can affect male fertility. Certain diseases or conditions, such as diabetes, thyroid disease, Cushing’s syndrome, or anemia may be associated with infertility.

AgeA gradual decline in fertility is common in men older than 35.

Possible Causes

General Health

Even in the absence of systemic illness, poor general health will impair fertility.

Aim for an ideal BMI.

In those who are overweight (BMI 25 to 30) and obese (BMI>30) there is a relationship between the degree of excessive weight and poor quality and quantity of sperm.11

The adverse effects of smoking on male fertility are inadequately appreciated.12,13

Excessive alcohol consumption also impairs fertility.14

The effect of lower levels of consumption does not seem to have been adequately researched.

Male exposure to recreational drugs, toxic substances in the workplace and ionising radiation do not seem to have a significant effect on fertility, but may cause an increase in congenital malformations, spontaneous abortions, fetal resorption, low birth weight infants, increase in childhood cancers, developmental and behavioural abnormalities.15

Past abuse of anabolic steroids may cause infertility.16

It is reasonable to suggest that anyone intent on embarking on the rigours of fatherhood should show responsibility with regard to alcohol, drugs and other aspects of lifestyle.

Disorders of the Testis and Spermatogenesis

These may be structural or hormonal.

Persistent azoospermia is incompatible with fertility.

Whilst a low sperm count is a poor prognostic feature, and the lower the count the worse the prognosis, it is not totally incompatible with fertility.

Klinefelter’s syndrome with karyotype XXY is associated with hypogonadism and disorders of spermatogenesis.

Failure of descent of the testes has already been mentioned.

Early orchidopexy is required to permit normal development.

Testicular feminisation is when there is resistance to the virilising effects of androgens and a child with an XY karyotype appears as a girl.

This can be much less complete and more limited resistance to androgens can lead to poor development of the testes.17

Testicular tumours are usually treated by orchidectomy, possibly followed by radiotherapy.

In men presenting with infertility and abnormal semen analysis there is a 20-fold increase in the risk of testicular cancer.18

Treatment of testicular cancer reduces fertility by 30%, but this is most marked in those who have received radiotherapy.19

Traditional teaching has been that varicocele results in a warmer environment for the testis and that this impairs spermatogenesis and fertility.

There has been much dispute over the years about the significance of varicocele, but an interesting recent observation is that varicocele is more associated with secondary than primary infertility and so it may be responsible for a premature decline in sperm count.20

Trauma can cause testicular damage.

Pituitary tumours will displace or destroy normal tissue and the production of FSH and LH is often the first to be affected.

Panhypopituitarism is also called Simmond’s disease.

Hyperprolactinaemia rarely present with galactorrhoea in men.

In one study it caused gynaecomastia in 8% of men but impotence in 30%.21

The control of prolactin is unlike the other releasing factors in that it is controlled by an inhibiting rather than a releasing factor from the hypothalamus into the hypothalamic-pituitary portal circulation.

It is also released in response to thyrotrophin releasing factor, as is TSH, and so it is elevated if thyroxine is low.

The pituitary gland may be responsible for other disorders such as Cushing’s syndrome.

Low levels of testosterone are found in 20 to 30% of infertile men, but giving testosterone does not improve fertility.16

Disorders of the Genital Tract

Failure of adequate differentiation of the embryonic testis can cause failure of proper development of the spermatic ducts.

In vasectomy the objective is to interrupt the vas deferens and it may be possible to reunite this in an attempt to reverse the procedure but the success rate as measured by successful pregnancy is poor.

Congenital urogenital abnormalities such as hypospadias can cause problems. It tends to deposit the semen in the acid environment of the vagina rather than near the friendlier environment of the cervix.

Does the possession of just one testis impair fertility?

In theory it should reduce the sperm count by 50% that would have no significant effect on fertility.

However, the loss of the testis may have been associated with other problems that may have had an adverse effect on the other one such as chemotherapy or radiotherapy for cancer.

Where a single testis has been lost or failed to develop in the absence of other problems, the presence of just one testis does not have an adverse effect on fertility.

Preventing Male Infertility

Often preventing infertility is much easier and better than treating it! What can you do to reduce the risk of being infertile ? The biggest preventable danger to male fertility is due to uncontrolled sexually transmitted diseases (STDs) such as syphilis, gonorrhea and chlamydia which can cause irreparable damage to the reproductive tract . Another important preventable cause of testicular damage in men is uncorrected undescended testes. Undescended testes should be surgically treated at an early age to prevent damage – preferably before the age of 2 years. This requires educating mothers of young boys; and doctors as well. It may also be a good idea to immunise boys against mumps in childhood, thus preventing the ravage which mumps can cause to the testes in later life.

Drugs – including alcohol, cocaine and marijuana – are all poisons. They can reduce sex drive; damage sperm production; and interfere with ovulation – and sometimes this damage is irreparable. Smoking tobacco also affects reproductive function – by depleting egg production; increasing the risk of PID; and lowering sperm counts. Often, the adverse effect is temporary, so that when these are stopped, the harmful effects on reproductive function are likely to be reversed. However, since abstinence is easier than moderation, the best option is not to smoke, drink or use drugs

Occupational hazards can also decrease sperm counts. Many toxic drugs – including radiation, radioactive materials, anesthetic gases, and industrial chemicals such as lead, the pesticide DBCP and the pharmaceutical solvent ethylene oxide can reduce fertility by imparing sperm production. Intense exposure to heat in the workplace (for example, long-distance truck drivers exposed to engine heat; and men working in furnaces or in bakeries) can cause long-term and even permanent impairment of sperm production. You should be aware of these hazards and may need to control your exposure if fertility is a concern.

Interestingly, many researchers have observed that sperm counts the world over are declining. Whether this is due to exposure to toxic chemicals such as dioxins ( formed as a result of environmental pollution) , which cause disruption of the endocrine system; or to the stresses of modern day life remains unclear.

What can you do to improve your sperm count ? Stop smoking, drinking or abusing drugs. Most doctors will advise that you take vitamins ( such as Vitamin E, Vitamin C); and others prescribe antioxidants and selenium, though the effect of these on male fertility is still a contentious issue. Traditional advise included taking cold water showers and wearing loose underwear, to help keep the testicular temperature low and “ sperm friendly “, but the results can be unpredictable. Certain drugs ( for example, salazopyrine which is used for treating ulcerative colitis) can suppress sperm counts, so if you are taking prescription medicines, ask your doctor about what their effect on sperm counts it. One simple way of increasing your chances of getting your wife pregnant is to have sex frequently – the more the sperm you deposit, the better your chances of hitting the jackpot!

Prevention

Does cigarette smoking affect male fertility?

Research on the effect of smoking on semen quality is unclear. However, it is generally recommended that men quit smoking if they are trying to have children. A greater number of birth defects have been found in the children of men who smoke heavily.

Does alcohol affect fertility?

What sexually transmitted infections can affect fertility?

Sexually transmitted infections (STIs), such as gonorrhoea, can damage the epididymis, preventing sperm from passing from the testes into the ejaculate. Genital herpes, while not affecting sperm production or transport, is a problem when spread to a female partner, particularly if a couple is trying to get pregnant.

It is important for men who think they may have a STI to get immediate treatment from a doctor. This can stop the spread of the disease to a partner and also reduce the chance of blockages developing in the male reproductive tract. Safe sex practices involving the use of condoms are generally recommended when not attempting to have a family.

Both partners may want to be tested for STIs before trying to have a family. This may stop any disease being passed on to partners or children.

Do underwear styles really affect fertility?

There is ongoing debate about the effect of underwear styles on sperm production.

Whether looser (cooler) boxer shorts are better than tighter (warmer) briefs is unclear. Some research has suggested that wearing tight underwear can decrease sperm counts, although other studies have not found this to be the case.

Doctors usually suggest that patients reduce the chances of heat stress on sperm production by avoiding tight-fitting clothing.

How do spas and saunas affect fertility?

It is generally recommended that men avoid spas, saunas and hot baths if trying to father a child. Raising the body temperature, and particularly the temperature around the testes, can reduce sperm production. Sperm need a cooler environment to develop.

What work environments affect fertility?

Although there is no clear evidence that certain work environments affect fertility, it is generally recommended that couples trying to become pregnant avoid exposure to any possible harmful chemicals. Pesticides, heavy metals, toxic chemicals and radiation may affect the quality and quantity of sperm produced.

Do recreational drugs affect fertility?

Androgens (anabolic steroids) taken for body building or sporting purposes, reduce sperm production by stopping the hormones made by the pituitary gland. Androgens can also be harmful to general health if men who have normal testosterone levels take them. These drugs should be stopped immediately, particularly if a couple is trying to have a baby.

Other illegal use of drugs, such as marijuana, may also affect fertility. There is some proof of a harmful effect on testicular function in some men, therefore it is suggested that men avoid using these drugs.

How do vaginal lubricants affect the chances of becoming pregnant?

Many vaginal lubricants are toxic to (kill) sperm. If couples are trying to become pregnant, the use of vaginal lubricants should not be used during the fertile time in the female partner’s menstrual cycle.

Is age important when trying to have a family?

It is well known that the chances of becoming pregnant drop as a woman becomes older. This is particularly true for women using IVF procedures. After a woman is over 35 years, the chance of assisted reproduction being successful are reduced, even if the infertility problem is mainly due to the man.

New research has shown that men’s fertility slightly drops with age. It can take longer for couples to become pregnant once the man is over 45 years of age. The amount of semen ejaculated (semen volume) and the movement of the sperm (sperm motility) also seems to decrease as men get older.

Why is sperm storage recommended before some treatments?

Sperm storage is the collection (through masturbation) and freezing of semen. Men about to start treatment that could make them infertile, may want to consider storing sperm before starting treatment. If and when a couple want to have a family this semen can be thawed and used in fertility treatments such as vaginal insemination at the time of ovulation or, in some cases, through IVF (in vitro fertilization).

All men and teenage boys, who have started or passed puberty, and who are about to receive chemotherapy or radiotherapy should consider sperm storage before their cancer treatment starts.

Men who need to take medicines for other health reasons when they are also trying to start a family, should check with their doctor to make sure that the medicine does not cause infertility. If medicines cause infertility, such as Salazopyrin® (used to treat inflammatory bowel disease), men can also store sperm before starting treatment.

Men who have taken hormone treatments in order to improve sperm production, but wish to stop this therapy after their first child has been born, may wish to store some sperm for later possible pregnancies.

Men planning a vasectomy should think about storing sperm before having this procedure. This may remove the possible need for vasectomy reversals or IVF at a later stage.

Azoospermia

If you and your partner are finding it difficult to get pregnant, it may be a good idea to visit your local fertility clinic for a physical workup. Here, your reproductive endocrinologist will analyze both male and female factors in order to find out exactly what is going on with your fertility.

Sometimes, male factor infertility can play a large role in pregnancy difficulties. Azoospermia can cause serious problems with sperm production and transfer, preventing a man’s sperm from entering his ejaculate. This can make pregnancy very difficult, if not impossible. However, new techniques are now being performed to help men with azoospermia father biological children.

What is Azoospermia?

Azoospermia is one of the most severe forms of male factor infertility. It is a condition in which a man has no sperm in his ejaculate.

In order to transport sperm outside of the body, it mixes with ejaculate (semen) at certain places throughout the male reproductive system. Sometimes, due to blockages or sperm production problems, sperm does not mix with ejaculate, and therefore cannot leave the body. This is why so many men with azoospermia find it difficult to have children.

Types of Azoospermia

Obstructive Azoospermia: Obstructive Azoospermia – The result of obstruction in either the upper or lower male reproductive tract (epididymis, vas deferens, seminal vesicles or ejaculatory ducts). Sperm production may be normal (which may be verified through testicular biopsy or aspiration), but the obstruction is preventing the sperm from being ejaculated. Some causes of obstructive azoospermia are vasectomy, congenital absence of vas deferens, scarring from past infections, and hernia operations, or some genetic conditions such as Cystic Fibrosis. Some sperm may be found and extracted directly from the testicles.

Non-obstructive Azoospermia: Severely impaired or non-existent sperm production in the testicle. The function of the testicle is twofold. One is production of male hormones, and the other is production of sperm. Insufficiency of one or the other is frequently congenital, but in some situations can be acquired during one’s life. If the system of the testicle which produces hormones is impaired, the hormones could be substituted by numerous preparations readily available. Unfortunately, if the system producing sperm is impaired or missing, the only substitute is donor/surrogate semen. Many couples in similar situations prefer using semen form a properly screened donor under a physician’s supervision, compared to adoption. Sometimes the genetic and biological information about the adopted child are not available; sometimes care of the child after birth has been deficient and improper, leading to the acquisition of various diseases, for example HIV/AIDS and many others.

How Common is Azoospermia?

Azoospermia affects only about 2% of the general male population; however, it does account for a large percentage of those men actively seeking fertility treatments. It is thought that between 10% and 20% of men undergoing fertility treatments suffer from azoospermia. Most of these men have little or no sperm present in their ejaculate.

Symptoms of Azoospermia

Unfortunately, it is very difficult to recognize azoospermia without undergoing fertility testing. This is because there are no symptoms that occur along with the condition. You will likely have semen of a normal color and texture, and will encounter few difficulties with ejaculation. Only a sperm count can diagnose the condition.

Causes of Azoospermia

The are typically two main causes of azoospermia: a problem with sperm production or a problem with sperm transport. There are a variety of factors that may contribute to either of these causes.

Sperm Production Problems

Sometimes, azoospermia is the result of a dysfunction within the testes themselves, making it impossible for your body to produce enough viable sperm. In order to produce sperm, the proper cells need to be present in the testes and the proper hormones need to trigger sperm production. Failed sperm production is often the result of:

Hormonal imbalances caused by anabolic steroid use or particular disorders, like Cushing’s Syndrome, can contribute to azoospermia.

Cryptorchidism

Cryptorchidism, or undescended testicles, is a condition in which your testes have not descended properly.

It is generally corrected in childhood, however, if it isn’t corrected, your testicles will be unable to produce sperm properly.

Vascular Trauma

Trauma to the testes or to the blood vessels within the testes can also prevent your body from producing sperm. Varicocele causes veins in the testes to enlarge and become swollen. As a result, blood pools in the testes, impairing sperm production.

Sperm Transport Problems

In order for sperm to leave your body, it must be transported from your testes to your urethra. Sperm travels through a series of ducts inside of your reproductive system, until it eventually mixes with your ejaculate and exits your body.

Sometimes, blockages can occur inside of these ducts preventing sperm from mixing with your ejaculate. Sperm transport problems are often caused by:

Vasectomy: The vasectomy procedure introduces a cut or blockage into your vas deferens, preventing sperm from mixing with your ejaculate.

Congenital Absence of Vans Deferens: Some men are born without the vas deferens, which are tiny tubes that carry sperm to the urethra for ejaculation.

Infection: Certain infections, including STDS, can cause blockages in the epididymis or vas deferens, preventing sperm from mixing with your semen.

Causes of Obstructive Azoospermia

Genetic

You may have been born with genes that may cause infertility. A gene is a piece of DNA that tells your body what to do or what to make. Genes may affect sperm transport, such as in congenital bilateral absence of the vas deferens.

Infections

Infections of the male reproductive system, such as in the testicles or prostate, may affect male fertility.

Trauma

Previous injury or surgery to the spine, pelvis, lower abdomen (stomach), or male sex organs may cause damage to the male reproductive system. This may include surgery on an inguinal (groin) hernia. Trauma may affect sperm production or cause an obstruction in the flow or transport of sperm.

Varicocele

A varicocele is a condition where the veins (blood vessels) in the scrotum are enlarged and dilated (widened). Ask your caregiver for information about varicocele.

Vasectomy

A vasectomy is a surgical procedure that is done on males as a method of birth control. The vas deferens (tubes that carry sperm from the testicles to the seminal vesicles) are cut, tied, or burned. The semen that is ejaculated no longer contains sperm.

Nonobstructive Azoospermia

Drugs

Certain drugs, such as steroids, antibiotics, and drugs to treat inflammation or cancer may affect male fertility. Smoking, drinking alcohol, and using illegal drugs may also cause problems with sperm production.

You may have been born with genes that may affect sperm production, such as Klinefelter’s syndrome. These genes may also affect the formation of your reproductive (sex) organs, such as Kallmann’s syndrome.

Hormones

Disorders of the testicles may produce abnormal levels of hormones that may affect the production of sperm.

Radiation

Radiation, such as that used to treat cancer, may affect sperm production.

Retrograde Ejaculation

Retrograde ejaculation is when semen travels into the bladder instead of outside the body. It is usually caused by a problem with the neck of the bladder and may be due to spinal cord injuries, medicines, or diabetes.

Other Factors

Pesticides, heavy metals, heat, and undescended testes (testicles that did move from the abdomen into the scrotum) may affect sperm production.

What are the signs and symptoms of Azoospermia?

You may have any of the following:

Inability to get your partner pregnant.

Increased body fat, body hair, and breast tissue.

Clear, watery, or whitish discharge from the penis.

Presence of a mass or swelling on the scrotum that feels like a bag of worms (varicocele).

Stress or emotional pressure from not being able to conceive a child.

Testicles that are small, soft, or non-palpable (cannot be felt).

Veins that are enlarged, twisted, and may be seen in the scrotum (varicocele).

How is Azoospermia diagnosed?

Your caregiver will take a complete medical, reproductive, and sexual health history from you. He may need to know how long you have been trying to have a baby. The timing and frequency of your sexual activities, and problems with sexual urges and functions are also important. You will also be asked about your lifestyle, including alcohol intake and smoking, medications taken, and past diseases. You may need any of the following:

Physical Examination

Your caregiver will look for signs of any imbalance in your hormones, such as increased body fat, body hair, and breast tissue. The size and shape of your testicles will also be examined. Your caregiver may also do a digital rectal exam (DRE) to check your prostate and other parts of your reproductive system.

Biopsy

A sample of your testicle is taken by a needle or through a small incision (cut) in the scrotum. The sample is sent to a lab for tests. This will help determine the ability of the testicles to produce normal sperm.

Blood Tests

You may need blood taken for tests. The blood can be taken from a blood vessel in your hand, arm, or the bend in your elbow. It is tested to see how your body is doing. It can give your caregivers more information about your health condition. You may need to have blood drawn more than once.

Genetic Screening

Genetic testing may be done to look for abnormal genes. Abnormal genes may cause problems with sperm production, sperm transport, or formation of the male reproductive organs.

Imaging Tests

Dye may be used in certain tests to make pictures show up better. Tell your caregiver if you are allergic to shellfish (lobster, crab, or shrimp), as you may also be allergic to this dye. Imaging tests may include the following:

Magnetic Resonance Imaging Scan

This test is also called an MRI. An MRI uses magnetic waves to take pictures of your pituitary gland to check for other causes of your infertility. You will need to lie still during an MRI. Never enter the MRI room with an oxygen tank, watch, or any other metal objects. This may cause serious injury.

Spermatic Venography

This test will examine and show the position of the veins in the scrotum. It may be used to check for a varicocele.

Ultrasonography

A scrotal or transrectal ultrasound uses sound waves to find lumps and other changes in your testicles and scrotum. These tests may be used to check for a varicocele or any missing parts of the reproductive system.

Semen Analysis

A semen analysis is a test to check a man’s fertility. It is done by taking a semen sample. You may need to talk with your caregiver about the method of sample collection.

Urinalysis

Post-ejaculatory urinalysis is a test that is done on your urine after you have ejaculated. This test looks for the presence of sperm in the urine, which may suggest an obstruction or problems with ejaculation.

Treatment

Treatment for Azoospermia by Dr. & Hakeem Tariq Mehmood Taseer

This treatment by Dr. Tariq Mehmood Taseer is especially for males with no sperms/ very less negligible sperms. A highly effective herbal and natural treatment to cure Azoospermia.

Oligospermia

Low sperm count (oligospermia) is one cause of male infertility. Although it takes only a single sperm to fertilize an egg (ovum), the odds of a single sperm reaching the egg are very low. For this reason, having a low sperm count decreases your chance of getting your partner pregnant.

The lower your sperm count, the more likely you’ll have trouble fathering a child. But treatments for male infertility related to low sperm count can help. Urologists are skilled in evaluating men with fertility problems and can recommend treatment.

In addition to evaluating and treating male fertility problems such as low sperm count, your doctor may also suggest treating your female partner to increase her fertility. This can help compensate for male infertility. If other treatments aren’t effective, artificial insemination or in vitro fertilization can be used to produce a pregnancy when low sperm count is a factor

Symptoms

For most men, the only sign of low sperm count men is the inability to conceive a child (infertility. A couple is considered infertile if they’re unable to conceive after one year of regular intercourse. If sperm production is impaired by an underlying hormonal problem, you may have other signs such as decreased facial or body hair or problems with sexual function.

Varicocele. This is a swollen vein inside the scrotum that can affect sperm production. This common cause of male infertility can be repaired with minor surgery.

Damaged sperm ducts. Inherited conditions, infections, surgeries or injuries can damage the delicate duct system that carries sperm from the testicles into the penis.

Anti-sperm antibodies. Men who have anti-sperm antibodies have an immune system response that attacks their own sperm. Common in men who have had a vasectomy reversal, this condition can also be caused by other problems such as an injury or infection.

Problems with Sperm Production

These issues can be caused by a genetic (inherited) condition such as Klinefelter’s syndrome or a hormonal disorder such as a health problem that affects the pituitary gland in your brain. If you have an inherited condition, you’re more likely to have complete lack of sperm in your semen (azoospermia).

Risk Factors

Factors that increase your risk of low sperm count include:

Genetic or hormonal problems. Certain health conditions affect sperm production, such as Klinefelter’s syndrome or a problem with hormone production.

Substance abuse. Sperm count can be reduced by use of illegal drugs such as cocaine or marijuana.

Certain surgeries or injuries. Surgeries or injuries that affect the testicles or glands that produce hormones can affect sperm production.

Prevention

A number of factors can help you maintain higher numbers of healthy sperm — and increase your chances of conceiving a child. Here are a few lifestyle decisions that may help:

Don’t smoke. Smoking can damage sperm and interfere with sperm production and libido. Secondhand smoke also may cause low sperm count.

Avoid excessive drinking. Excessive alcohol consumption (more than two drinks a day for men) has been shown to reduce sperm production and affect libido.

Steer clear of illegal drugs. Drugs including anabolic steroids, marijuana and cocaine can all affect sperm production and libido.

Keep the weight off. Obesity is linked to decreased sperm production.

Don’t get a vasectomy. If there’s any possibility you may want to father a child in the future, use other methods of birth control. Even though vasectomies can sometimes be reversed, you may have a reduced sperm count.

Keep cool. Avoid hot tubs, saunas and other sources of sustained heat, which can temporarily reduce sperm count. Tight underwear and sitting for long periods or using a laptop computer also may increase scrotal temperature.

Abnormalities in Sperm

Teratozospermia

This is reduced levels of normally shaped sperm less than 15% sperm of normal morphology.

A very low volume i.e. less than 0.5 ml may indicate a problem in producing the specimen (including missing the container), a dysfunction with the accessory glands or retrograde ejaculation.

High semen volume but low sperm numbers no need of semen concentration our medicine will take care of this problem.

Abnormal pH

An abnormally low pH i.e. less than 7.0 may indicate retrograde ejaculation when combined with a very low ejaculate volume. A pH of below 7.0, normal volume and azoospermia may indicate an obstruction of the ejaculatory ducts or congenital bilateral absence of the vas in this case result is poor.

An abnormally high pH i.e. greater than 8.5 may indicate an infection or dysfunction of one of the accessory glands result is good.

If greater than 50% of sperm are immotile then the analysis will determine whether the sperm are immotile or dead. This will determine whether the sperm immotility is due to cell death or a motility defect.

Increased cell death may be treatable if the cause is identifiable e.g. partial blockage, increased abstinence periods, infection. Immotile sperm can be used for assisted conception purposes as long as they are alive.

Lifestyle and Home Remedies

Taking care of yourself can help increase the number of healthy sperm in your semen.

Frequency of ejaculation. It’s important to have sex on a regular basis around the time of ovulation, when your partner can get pregnant. But ejaculating more than a few times a week can reduce the number of sperm present in your semen.

Avoid the heat. High body temperatures have been shown to decrease sperm production. Avoid hot tubs, saunas and exposure to hot weather. Tight fitting shorts or prolonged laptop computer use also may increase the temperature of your testicles, decreasing sperm production.

Make healthy lifestyle choices. Staying at a healthy weight and avoiding tobacco, excessive drinking and illegal drugs can all help reduce the risk of low sperm count.

Tests and diagnosis

When you see a doctor because you’re having trouble getting your partner pregnant, your doctor will try to determine the underlying cause. Sperm production is complex and requires normal functioning of the testicles (testes) as well as the hypothalamus and pituitary glands — organs in your brain that produce hormones that trigger sperm production. Problems with any of these systems can affect sperm production.

Initial Examination

Expect to answer detailed questions about your medical history and any sexual issues. Your doctor will do a careful physical examination of your reproductive organs to look for signs of a problem such as a varicocele — a varicose vein of the testicle.

Semen Analysis

Low sperm counts are diagnosed as part of a semen analysis test. Sperm count is generally determined by examining semen under a microscope to see how many sperm appear within squares on a grid pattern. In some cases, a computer may be used to measure sperm count. If you have no visible sperm in your semen sample, your doctor may use a more involved test to try to isolate any sperm present in your semen for examination.

To collect a semen sample, your doctor will have you masturbate and ejaculate into a special container. It’s also possible to collect sperm for examination during intercourse, using a special condom. Because measurements from sample to sample can vary widely, you’ll need to present a few samples for your doctor to get a clear picture of the quantity — and health — of your sperm.

Normal sperm densities range from 20 to greater than 100 million sperm per milliliter of semen. While men can reproduce with much lower numbers of sperm, your chance of getting your partner pregnant decreases along with decreasing sperm counts:

Less than half the men with sperm counts between 12.5 and 25 million sperm per milliliter are able to get their partner pregnant.

Less than one-quarter of men with sperm counts less than 12.5 million sperm per milliliter are able to get their partner pregnant.

There are many factors involved in reproduction, and some men with low sperm counts have fathered children. Likewise, some men with normal sperm counts have been unable to father children. The number of sperm in your semen is only one factor. Even if you have enough sperm, you’re much more likely to achieve pregnancy if at least half of your sperm have a normal shape and show normal forward movement (motility).

Your doctor may conduct further tests if he or she suspects your low sperm count is caused by an underlying condition. Your doctor will also want to make sure your female partner has been tested for any fertility problems.

Ultrasound

If your doctor suspects your reproductive tract is blocked, he or she may order an ultrasound test. Scrotal ultrasound is used to detect a varicocele or blocked epididymis.

Testicular Biopsy

This procedure uses a fine needle to take a small tissue sample of the testicle to look for any abnormalities and to determine if sperm are present. The doctor will numb the area where the samples will be taken (generally one from either testicle). The procedure isn’t painful, but you may feel sore for a few weeks afterward.

Blood Tests and Genetic Tests

If your doctor suspects your low sperm count may be caused by an underlying hormonal condition, your doctor may test your blood for hormone levels. In some cases, problems with sperm production are linked to a genetic (chromosomal) abnormality. If your doctor suspects this is the case, genetic testing can be used to check for absent or abnormal regions of the male chromosomes (Y chromosomes).

It is the fastest among all treatment. It raises sperm count fourfold with every month’s treatment till optimum count. So with low sperm count like 3 million per ml. to normal count of 40 million per ml. can be achieved within two months of treatment.

The lowest count which can be helped is 1 lac per ml or 0.1 million per ml. Below, this the result may be variable.

It does not support azoospermia or zero count at all.

It improves not only sperm count but also it’s quality. It raises low sperm motility to high sperm motility. It also improves grades of sperm motility simultaneously.

The success rate of system is very high. In about 3000 patients, it succeeded in 95% of the patients.

The Medicine provide by us are free from hormone.

The duration of the treatment is very short. It clears the case in one month to four months.

It has no restrictions during the treatment. No food restrictions. The only restriction is to avoid taking male hormones, as male hormone testosterone can block the good affect of this treatment. So, the patient should avoid taking any male hormones at least from one month prior to taking this treatment.

The greatest advantage is that even after stopping the treatment the higher count remains longer, where as in male hormones, it falls as soon as the treatment is stopped.

It is quite comfortable to take it, as it has sweet pills and drops only, to take with few doses per day.

So, this treatment being simpler avoids complicated procedures in case of male infertility.

Precaution Before and During Treatment

No oral or Hormonal treatment is allowed at least one month prior to this treatment and during the course of treatment.

Semen analysis report is must before starting treatment, so one can know the effect of treatment at middle and end of treatment.

Extra food supplements, Vitamins and other sexual tonic should be avoided during treatment.

Pure herbal treatment by Dr. Tariq Mehmood Taseer to cure infertility/low sperm count in males with well proven results. Has a very high success rate in treating different causes of infertility in males. Dosage and duration of the treatment may vary as per the patient profile. Treatment is without any side effects.

Necrospermia

When semen has less of mature normal sperms & more of dead sperms this condition is abnormal. When ever there is less of normal sperm then chances of spontaneous pregnancy decreases (i.e. difficulty in conceiving i.e. wife does not becomes pregnant). This is one of the common causes of male factor infertility. This is also one of the most common semen abnormalities in men.

How sperms develop: When boy becomes of 14 years of age then L.H. & F.S.H. hormone secretion from pituitary increases. The rise in these hormones leads to proliferation of sperm forming cells (Germ Cells) in the testis. These germ cells start multiplying under the effect of above-mentioned pituitary hormones along with assistance of other hormones as testosterones, Growth hormones, Androstenidione, insulin like growth factor-I, Thyroids hormone, paracrine hormone & growth factors. Under the control of above-mentioned hormones germs cells divide & transformed into primary spermatocytes. Then further maturation of primary spermatocytes to spermatids & then finally into mature spermatozoa (i.e. normal sperms) occurs under the control of above-mentioned hormones. After few weeks of progressive maturation inside the testis these sperms become normally motile & develop the capacity to fertilize the ovum. This total sperm cycle from first stage to final stage of normal mature sperms is of three months. Any hindrance in the development of these spermatozoa will lead to dead sperms, less count of sperm & decreased motility, immotile or even dead sperms.

Varicocele: varicocele is dilatation of scrotal vein in the scrotum that leads to rise in temperature of testis and raise testicular temperature, resulting in less sperm production & death of whatever sperms are produced.

Autoimmunity i.e. presence of Antisperm antibody. These Antisperm antibodies bind with sperms & either make them less motile, totally immotile or even dead which is called necrospermia.

Undescended Testicle (cryptorchidism). Undescended testis is a condition when one or both testicles fail to descend from the abdomen into the lower part of scrotum during fetal development. Undescended testicles can lead to less sperm production. Because the testicles temperature increase due to the higher internal body temperature compared to the temperature in the scrotum, sperm production may be affected.

Mosaic Klinefelter’s syndrome In this disorder of the chromosomes, of the man is abnormal. This causes abnormal development of the testicles, resulting in low sperm production. Testosterone production may be low or normal.

Development and structural defects as mild degree of Germinal cell hypo-plasia

Partial Androgen resistance

Mycoplasmal infection

Partial Immotile cilia syndrome

Partial Spermatogenic arrest due to interruption of the complex process of germ cell differentiation from spermatid level to the formation of mature spermatozoa results in decreased sperm count i.e. oligospermia. Its diagnosis is made by testicular biopsy. This is found in upto 30% of all cases of dead sperm patients.

Heat Exposure to testis: as febrile illness or exposure to hot ambience induces a abnormality in spermatogenesis.

Infection – as bacterial epididimo-orchitis, even in prostatis spermatogenic defect have been noted

Hyper-thermia due to cryptorchidism

Chromosomal abnormality: has been found in many cases of low sperm count

Anti-sperm antibodies. In some people there occurs development of some abnormal blood proteins called anti-sperm antibodies, which binds with sperm and make them either immotile or dead or decrease their count.

Infections. Infection of uro-genital tract may affect sperm production. Repeated bouts of infections are one of the common causes associated with male infertility.

Klinefelter’s syndrome. In this disorder of the chromosomes, a man has two X chromosomes and one Y chromosome instead of one X and one Y. This causes abnormal development of the testicles, resulting in low or absent sperm production. Testosterone production also may be lower.

Trauma to testis

Environmental toxins: as Pesticides and other chemicals in food or as ayurvedic medicines.

Genetic Factors: as idiopathic partial hypo-gonadotropic hypogonadism

Diagnosis of Cause of Dead Sperms

For correct diagnosis of cause of more of Dead sperm, we need detail history & physical examinations then certain relevant investigations are required.

History & Physical Examinations: First step in proper treatment is accurate diagnosis of cause of dead sperms. So we first try to find out cause. We take detailed history, thorough drug history and general physical examination, examination of testis, epididymis, testicular veins & sperm carrying duct examinations. These examinations give idea about whether testis is normally developed or not & how is its function. After that depending on likelihood of particular, cause relevant tests are done. All testing facilities are available at our centre. Thus you may consult us at our centre & at same time you may get all tests done. The time taken in getting all the reports ready is 36 hours.

Investigation & Diagnosis: For completes diagnosis of causes of dead sperms one or more of the following tests may be required as

Complete male hormone profile: This profile includes all the male hormone tests which control testicular development, functions including normal sperm Productions. The tests include L.H., F.S.H., Testosterones, prolactins, thyroids test, & other relevant hormone tests depending on history & examinations.

Antisperm antibody

USG or Doppler study of scrotum & testis

Semen culture sensitivity

Semen fructose

Immunobead test

Sperm Function Tests

Human Sperm-Zona Pellucida Binding Ratio

Human Sperm-Zona Pellucida Pentration test

Genetic Studies

FNAC Testis

Egg penetration test

Molecular genetic studies done in some special cases

Chromosome analysis i.e. Karyotype

Assessment of androgen receptor

Combined Pituitary hormone tests is performed when needed

MRI head if pituitary hormone defect suspected

Hemogram test for systemic diseases.

Sperm Function Tests: The hamster egg penetration assay (HEPA) and the hemizona assay (HZA) are sperm function tests which can help assess the ability of sperm to penetrate the egg. These tests will not definitively tell whether a pregnancy will occur, but an abnormal test result helps predict reduced fertilizing capability. These tests are performed only rarely today.

Semen Fructose

Sperm Coiling Test to find out whether the particular sperm is live or dead

Treatment

Once the cause of low sperm count are found then with in three months of treatment sperm count & motility becomes normal in more than 90% cases.

The various treatments are as follows:

Correction of the Cause: First of all we try to find out the primary cause of infertility by above mentioned investigations. Then we correct the basic defect i.e. correction of hormone disorder & other defects. We also give following treatment for permanent cure of low sperm count & motility disorder.

Correction of Hormone deficiencies: Once the hormone disorder is found then it is corrected by any of the below medicines. Usually dead sperms problem is cured in three month time with proper hormone treatment.

Gonadotropin Therapy: Gonadotropins are most potent natural stimulators of sperm production in the testis. Once we start gonadotropin therapy, these gonadotropins stimulates the sperm producing cells in testis. Under the stimulating influence of gonadotropins dormant sperm forming cells which were not producing normal sperms, they start dividing & producing normal sperms. Thus in more than 90% cases sperm production can be normalized in three to four months time if it is started in properlyselected cases of low sperm count. Gonadotropin therapy is most successful of all the available treatment for dead sperms till now. In many cases of dead sperms, when all other treatment has failed even in those cases gonadotropin therapy is effective. Thus treatment of dead sperms with gonadotropin therapy results in pregnancy soon.

Repronex.

Bravelle

Ovidrel

Gonadotropin-releasing hormone (Gn-RH) analogs

Growth hormone therapy in many cases where somatotropin deficiency is found

Growth Factor, Mineral & Micronutrient Therapy

Free Radial Scavangers: These are drug to reduce the free damaging oxidative radical in the testis. For your information every minute lot of oxidant radicals are generated inside the testis which damages sperm forming cells. These special antioxidant drugs scavange these damaging oxidative free radicals thus leading to production of normal sperms by the testis. In many study these free radical scavengers have been found to be very-very effective in curing dead sperms.

Coenzyme ubique: These drugs improve the nutritional status of the testis. Thus testis as well as sperm forming cells get enough nutrient which helps in fast generation of normal sperms in good number with good motility & fertilizing capacity.

Carnititine supplementation increases the production of sperm, with normalization of normal sperms in semen in three months.

Fertyl: This drug is taken orally and it causes the pituitary gland to release more FSH and LH, which then stimulates the testis to produce more normal sperms.

Bromocriptine. This medication is for men who have elevated levels of prolactin.

Correction of thyroid hormone

Correction of congenital adrenal hyperplasia

Vitamins

Zinc

Methy-Predinisolone

Antibiotics

Antiestrogens

Tamoxifen

Clomiphene

Hgh

Antimicrobials

Anti-inflammatory

AIH

ART:The most common forms of ART include:

In Vitro Fertilization (IVF). This is the very effective ART technique. IVF involves retrieving mature eggs from a woman, fertilizing them with a man’s sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF often is recommended as a first-line therapy. It’s also widely used for unexplained infertility, male factor infertility.

Surgical Sperm Aspiration This technique involves removing sperm from part of the male reproductive tract such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if blockage is present.

Intracytoplasmic sperm injection (ICSI). This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.

Certain Newer Drugs has been found very effective

Surgery: Surgery is also the treatment of choice for significant varicocele. Similarly surgery may be one of the treatment options for many endocrine tumours.

Test tube baby is also delivered with our efforts by use of intra-cytoplasmic sperm injection (ICSI) after separating out live sperms out of dead ones then transfer of embryo to uterus of mother.

Semen Bank: Facility for good quality sperm is semen bank in also available. At our center we have facility for all the testing & treatment facility required for low sperm count to achieve pregnancy.

Varicocele ligation: A varicocele is an abnormal tortuosity and dilation of veins of within the scrotum. It can be surgically treated – which might help fertility in some cases.

Response Of Treatment

When we start treatment, maturation of spermatocyte to mature spermatozoa start occurring in three to 4 weeks time and achievement of normal sperm count with normal sperms is achieved in three months. Thus cure rate is achieved in more than 95% of patients in three months time.

Side Effects

This treatment is harmless because we prescribe well proven drugs which are prescribed in scientific literature. These medicines have to be purchased from medical store by patient himself.

Antisperm Antibodies

Normally, our bodies develop antibodies to help protect our immune system against illnesses. However, sometimes our bodies develop antibodies to the wrong thing, which can cause negative repercussions. Among infertile men, about 10% will be diagnosed with having antisperm antibodies, a condition that can significantly decrease your chances of pregnancy.

Immune Overdrive

Normally, the testes contain a natural barrier, known as the blood-testes barrier. This barrier acts a protective layer that prevents immune cells from being able to access sperm within the male reproductive tract. Yet, this barrier can be broken, through injury to the reproductive tract, thereby allowing the immune cells to come into contact with the sperm.

Once the barrier is broken, immune cells are able to detect the presence of sperm due to their unique antigen surface. This triggers a response by the immune system to treat sperm as an “invader” and attack it. Antibodies then attach themselves to different parts of the sperm and interfere with male fertility in a number of ways.

Antibodies that are located on the tail of sperm can cause the sperm to become immobilized or clump together. When antibodies are found on the head of sperm, they can prevent the sperm from being able to efficiently make its way through a woman’s cervical mucus to the egg. However, it is also possible for a woman to develop antisperm antibodies in her cervical mucus, which will only serve to hinder attempts at conception even more. It is thought that antisperm antibodies in cervical mucus could account for as much as 40% unexplained infertility cases.

Sperm that does manage to make it to the egg can have a difficult time properly binding and fertilizing the egg due to antibodies attached to its head.

Reason for Antisperm Antibodies

There are numerous reasons why the natural barrier between sperm and the immune system can be broken causing antisperm antibodies to form. Some of these factors include:

Injury to the testicles

Undescended testicles

Twisting of the testicles

Infection

Testicular cancer

Testicular biopsy

CAVD

Varicocele

Additionally, men who have undergone a vasectomy reversal are particularly prone to developing this fertility problem. Close to 70% of men who have had their vasectomy reversed will develop antisperm antibodies.

Treating Antisperm Antibodies

Detecting antisperm antibodies is usually fairly simple as a semen analysis should be able to identify whether the antibodies are present. It is also possible to do an individual test that looks specifically for antisperm antibodies on sperm or, in women, in cervical mucus. However, getting rid of the antibodies may not be as easy.

While the use of corticosteroids can decrease the number of antibodies, temporarily restoring fertility, it is necessary to use very high doses. These high doses often cause serious side effects, thereby making this solution less desirable. Women who have antisperm antibodies may be prescribed medications to suppress their immune system.

Assisted reproductive techniques have been found to be the most helpful for couples suffering from this problem. Some couples have found success with IUI as this involves depositing sperm directly into the uterus. This technique appears to work best in couples whose difficulties stem from the cervical mucus. Washing sperm before the procedure can also rid the sperm of most antibodies.

Overall, though,IVF has proven to be the most helpful method in helping couples with antisperm antibodies conceive. Again, washing sperm beforehand is often helpful. HOwever, in some cases, it may be necessary to incorporate ICSI into the treatment as well.

Antisperm Antibodies: How common are they?

Sperm are relatively protected from the immune system by a natural protective mechanism called the blood-testes barrier. Tight connections between the cells lining the male reproductive tract keep immune cells from gaining entry to the sperm within. If an injury breaches this barrier, then the immune system has access to sperm and antibodies are formed.

Antisperm antibodies have been reported in approximately 10% of infertile men, compared to less than 1% of fertile men. The prevalence of antibodies jumps dramatically in men who have had surgery on their reproductive tract: nearly 70% of men who have undergone a vasectomy reversal will have antibodies present on their sperm. Women have a much lower chance for developing antibodies to sperm: less than 5% of infertile women can be shown to have antisperm antibodies, and it is unclear who is at risk for their formation.

Who is at risk for Antisperm Antibodies?

Anything that disrupts the normal blood-testes barrier can result in the formation of antisperm antibodies. This may include any of the following conditions:

Vasectomy reversal

Varicocele (dilation of the veins surrounding the spermatic cord)

Testicular torsion (twisting of the testicle)

Congenital absence of the vas deferens

Testicular biopsy

Cryptorchidism (failure of testicular descent)

Testicular cancer

Infection (orchitis, prostatitis)

Inguinal hernia repair prior to puberty

Fortunately, intrauterine insemination (the placement of washed sperm into the uterine cavity – a common fertility treatment) has not been shown to cause antisperm antibody formation.

Despite the long list of risk factors, most men with antisperm antibodies have not had any of the conditions listed above. Therefore all infertile men are potentially at risk, and consideration should be given to testing infertile men for antisperm antibodies, especially if no other reasons for the infertility have been detected by the diagnostic workup.

How do antisperm antibodies cause infertility?

Antibodies that attach to the sperm may impair motility and make it harder for them to penetrate the cervical mucus and gain entrance to the egg; they may also cause the sperm to clump together, which is occasionally noted on a routine semen analysis. Antibodies may also interfere with the ability of the sperm to fertilize the egg.

What is the best way to detect antisperm antibodies?

Over the years, many tests have been developed to detect antisperm antibodies. In women, blood tests for antisperm antibodies in women may be more practical than trying to measure antibodies in the cervical mucus, which is the primary site where her immune system interacts with sperm. The postcoital test, which has been a standard part of the infertility evaluation, may suggest the presence of antisperm antibodies. By examining the cervical mucus following intercourse near the time of ovulation, antisperm antibodies may result in either a lack of sperm or in the presence of sperm, which are shaking in place rather than actively swimming through the mucus.

In men, a direct examination of their sperm for attached antibodies is more reliable than testing blood for the presence of antibodies. Two commonly used tests are the immunobead assay and the mixed agglutination reaction (MAR). Both tests use antibodies bound to a small marker, such as plastic beads or red blood cells, which will attach to sperm that have antibodies on their surface. The results are read as a percentage of sperm bound by antibodies.

What treatments are available for Antisperm Antibodies?

Suppressing the immune system with corticosteroids may decrease the production of antibodies but can result in serious side effects, including severe damage to the hipbone. Intrauterine insemination, with or without the use of fertility medications, has been used for the treatment of antisperm antibodies. It is believed to work by delivering the sperm directly into the uterus and fallopian tubes, thus bypassing the cervical mucus.

In vitro fertilization appears to be the most effective treatment for antisperm antibodies, especially when there are very high levels of antibodies (near 100% of sperm are bound by antibodies). There is no clear guidance on whether intracytoplasmic sperm injection (ICSI), the direct fertilization of an egg with a single sperm, is required for the treatment of antisperm antibodies, unless there had been a complete absence of fertilization on a prior attempt at in vitro fertilization.

Are there other antibodies that affect fertility?

For women with recurrent miscarriage, there are a group of antibodies that appear to attack an early developing pregnancy, resulting in either a miscarriage or severe preeclampsia with risk of intrauterine growth retardation or even fetal death. Collectively these belong to a class of antibodies known as antiphospholipid antibodies, which include the lupus anticoagulant and the anticardiolipin antibody.

Testing for these antibodies are an integral part of the workup for recurrent pregnancy loss. However, it is unclear whether these antibodies play any role in the ability to conceive. Some physicians believe that the presence of antiphospholipid antibodies may decrease the chance for pregnancy through in vitro fertilization. Although this is a controversial subject, one of the largest studies that looked for these antibodies in women undergoing in vitro fertilization found that these antibodies were no more likely to be detected in those who did not become pregnant as in women who did conceive.

Anti-sperm Antibody Testing

What are Antisperm Antibodies?

Anti sperm antibodies are antibodies directed against the sperm. Under normal conditions the immune system develop antibodies to help protect our immune system against illnesses. However, in the case of anti sperm antibodies the body develops and directs specific antibodies against the sperm which is the wrong approach and can cause negative side effects upon the health status of the sperm and can cause infertility in a man. In general, among infertile men, about 10% will be diagnosed with having antisperm antibodies, a condition that can significantly decrease their chances of pregnancy.

Normally, the testes contain a natural barrier, known as the blood-testes barrier. This barrier acts as a protective layer that prevents immune cells from being able to access sperm within the male reproductive tract. Yet, this barrier can be broken, through injury to the reproductive tract, thereby allowing the immune cells to come into contact with the sperm and recognize them as foreign bodies, which they are.

Once the barrier is broken, immune cells are able to detect the presence of sperm due to their unique antigen surface. This triggers a response by the immune system to treat sperm as an “invader” and attack it. Antibodies then attach themselves to different parts of the sperm and interfere with male fertility in a number of ways.

Normally there are three different types of antibodies produced by the body that can influence the well being of the sperm. Antibodies that are located on the tail of sperm can cause the sperm to become immobilized or clump together. When antibodies are found on the head of sperm, they can prevent the sperm from being able to efficiently make its way through a woman’s cervical mucus to the egg. Interestingly enough, it is also possible for a woman to develop antisperm antibodies in her cervical mucus, which will only serve to hinder attempts at conception even more. It is thought that antisperm antibodies in cervical mucus could account for as much as 40% in unexplained infertility cases.

Under normal conditions, sperm that does manage to make it to the egg encounter a great deal of difficulty properly binding and fertilizing the egg due to antibodies attached to its head. The etiology for the production of antisperm antibodies are several.

Some of these factors include:

Injury to the testicles

Undescended testicles

Twisting of the testicles

Infection such as testiculitis

Testicular cancer

Testicular biopsy

Varicocele associated with hestasis to the testes

It has been documented very clearly that men who have undergone a vasectomy reversal are particularly prone to developing this fertility problem. Publish reports put to 70% of men who have had their vasectomy reversed will develop antisperm antibodies.

Treatment

Pure herbal treatment by Dr & Hakeem Tariq Mehmood Taseer to cure Antisperm antibodies problem in males with well proven results. Has a very high success rate in treating different causes of this problem. Dosage and duration of the treatment may vary as per the patient profile. Treatment is without any side effects.

Premature Ejaculation

Important Facts

In premature ejaculation, a man ejaculates quickly after sexual arousal

Premature ejaculation, or rapid ejaculation, is a common type of sexual dysfunction

Causes for this condition usually are unknown, but it often is related to anxiety

Premature ejaculation (PE) is a term used to describe a condition in which a man regularly ejects semen (i.e., ejaculates) very soon after the onset of sexual arousal, or sooner than he or his partner wishes. This condition, which is also called rapid ejaculation, is the most common type of sexual dysfunction in men under the age of 40.

Premature ejaculation can be primary (in men who have had the condition since puberty), or secondary (acquired; in men who previously had control of ejaculation). It may develop in men who have erectile dysfunction (impotence) and are anxious about maintaining an erection during sexual intercourse.

Premature ejaculation often causes distress for the man and for his partner. When the condition regularly occurs before penetration, it may prevent pregnancy.

Definition

Many men occasionally ejaculate sooner during sexual intercourse than they or their partner would like. As long as it happens infrequently, it’s probably not cause for concern. However, if you regularly ejaculate sooner than you and your partner wish ï¿½ such as before intercourse begins or shortly afterward ï¿½ you may have a condition known as premature ejaculation.

Premature ejaculation is a common sexual disorder. Estimates vary, but some experts think it affects as many as one out of three men. Even though it’s a common problem that can be treated, many men feel embarrassed to talk to their doctors about it or seek treatment.

Once thought to be purely psychological, experts now know that biological factors also play an important role in premature ejaculation. In some men, premature ejaculation is related to erectile dysfunction.

You don’t have to live with premature ejaculation ï¿½ treatments including medications, psychological counseling and learning sexual techniques to delay ejaculation can improve sex for you and your partner. For many men, a combination of treatments works best.

Symptoms

There’s no medical standard for how long it should take a man to ejaculate. The primary sign of premature ejaculation is ejaculation that occurs before both partners wish in the majority of sexual encounters, causing concern or distress. The problem may occur in all sexual situations, including during masturbation ï¿½ or it may only occur during sexual encounters with another person.

Doctors often classify premature ejaculation as either primary or secondary:

You have primary premature ejaculation if you’ve had the problem for as long as you’ve been sexually active.

You have secondary premature ejaculation if you developed the condition after having had previous, satisfying sexual relationships without ejaculatory problems.

Incidence and Prevalence

Premature ejaculation affects males only and can occur at any age of adulthood. The condition is most common between the ages of 18 and 30. It is estimated that premature ejaculation affects from 30ï¿½70% of men during their lifetime.

The cause for premature ejaculation is unknown, although, in most cases, it is thought to be the result of psychological factors (e.g., anxiety, guilt). Rarely, the condition is caused by a physical problem, such as over sensitivity of the genitals or abnormal hormone (e.g., testosterone) levels. Certain medications (e.g., psychiatric drugs) may cause premature ejaculation.

Other factors that can play a role in causing premature ejaculation include:

Erectile dysfunction. Men who are anxious about obtaining or maintaining their erection during sexual intercourse may form a pattern of rushing to ejaculate which can be difficult to change.

Anxiety. Many men with premature ejaculation also have problems with anxiety ï¿½ either specifically about sexual performance, or caused by other issues.

Biological Causes

Experts believe a number of biological factors may contribute to premature ejaculation, including:

Abnormal hormone levels

Abnormal levels of brain chemicals called neurotransmitters

Abnormal reflex activity of the ejaculatory system

Certain thyroid problems

Inflammation and infection of the prostate or urethra

Inherited traits

Rarely, premature ejaculation is caused by:

Nervous system damage resulting from surgery or trauma

Withdrawal from narcotics or a drug called trifluoperazine (Stelazine), used to treat anxiety and other mental health problems

Although both biological and psychological factors likely play a role in most cases of premature ejaculation, experts think a primarily biological cause is more likely if it has been a lifelong problem (primary premature ejaculation).

Risk Factors

Various factors can increase your risk of premature ejaculation, including:

Impotence. You may be at increased risk of premature ejaculation if you occasionally or consistently have trouble getting or maintaining an erection. Fear of losing your erection may cause you to rush through sexual encounters. As many as one in three men with premature ejaculation also have trouble maintaining an erection.

Health problems. If you have a medical concern that causes you to feel anxious during sex, such as a heart problem, you may have an increased likelihood of hurrying to ejaculate.

Stress. Emotional or mental strain in any area of your life can play a role in premature ejaculation, often limiting your ability to relax and focus during sexual encounters.

Certain medications. Rarely, drugs that influence the action of chemical messengers in the brain (psychotropics) may cause premature ejaculation.

Tests and Diagnosis

Doctors diagnose premature ejaculation based on a detailed interview about your sexual history. Your doctor may ask a number of very personal questions and may want to include your partner in the interview. While it may be uncomfortable for both of you to talk frankly about sex, the details you provide will help your doctor determine the cause of your problem and the best course of treatment. A mental health professional may help make the diagnosis.

Your doctor will want to know about your health history, and may perform a general physical exam. You doctor may ask you questions about:

How often you have premature ejaculation

Whether you have premature ejaculation only with a specific partner or partners

Whether you have premature ejaculation every time you have sex

How often you have sex

How you feel premature ejaculation affects your enjoyment of sex and your quality of life

Whether you also have trouble getting and maintaining an erection (erectile dysfunction)

Your use of prescription medications and recreational drugs

To evaluate whether psychological factors may influence your premature ejaculation, your doctor or mental health professional may also want to know about:

Your religious upbringing

Your early sexual experiences

Your sexual relationships, past and present

Any conflicts or concerns within your current relationship

If you have both premature ejaculation and trouble getting or maintaining an erection, your doctor may order blood tests to check your male hormone (testosterone) levels or other tests.

Complications

Relationship strains. The most common complication of premature ejaculation is relationship stress. If premature ejaculation is straining your relationship, ask your doctor about including couple’s therapy in your treatment program.

Fertility problems. Premature ejaculation can occasionally make fertilization difficult or impossible for couples who are trying to become pregnant. If premature ejaculation isn’t effectively treated, you and your partner may need to consider infertility treatment.

Prevention

In some cases, premature ejaculation may be caused by poor communication between partners or a lack of understanding of the differences between male and female sexual functioning. Women typically require more prolonged stimulation than men do to reach orgasm, and this difference can cause sexual resentment between partners and add pressure to sexual encounters. For many men, feeling pressure during sexual intercourse increases the risk of premature ejaculation.

Open communication between sexual partners, as well as a willingness to try a variety of approaches to help both partners achieve satisfaction, can help reduce conflict and performance anxiety. If you’re not satisfied with your sexual relationship, talk with your partner about your concerns. Try to approach the topic in a loving way and to avoid blaming your partner for your dissatisfaction.

If you’re not able to resolve sexual problems on your own, talk with your doctor. He or she may recommend seeing a therapist who can help you and your partner achieve a fulfilling sexual relationship

To Learn Ejaculatory Control

Don’t use drugs or alcohol. They’re distracting and they interfere with the self-awareness crucial to learning ejaculatory control.

Appreciate whole-body sensuality. Men often think sex happens only in the penis and only during intercourse. That view is a one-way ticket to premature ejaculation (not to mention erection problems, and women with those proverbial headaches). The best sex involves head-to-toe arousal. Men learning how to approach — but not arrive at — their point of no return, need to appreciate whole-body sensuality, the pleasure potential in every square inch of the body. Whole-body sensuality releases tension. Tense bodies that have no other outlet often find release through involuntary ejaculation. But as you learn to appreciate sensual pleasure from head to toe, whole-body arousal takes the pressure off your penis, and you last longer.

Whole-body sensuality means relaxation, but the “relaxation” involved in great sex is not the kind that includes an easy chair, a six pack, and Monday Night Football. It’s the kind you feel after a hot bath or a good massage. In fact, bathing or showering together before lovemaking can help men relax and appreciate whole-body sensuality — and last longer.

Breathe deeply. One very easy way to stay relaxed while making love is to breathe deeply. The body has a natural tendency to breathe deeply during sex. But many men fight it. They think they should stay in control by not breathing deeply and making the little love-moan sounds that go along with it. But when men work to control their breathing, they often sacrifice ejaculatory control. Try breathing deeply. Let your breath go. Many men are amazed how much this one little change improves their premature ejaculation.

Start with masturbation with a dry hand. By varying how you caress your penis, you can learn to stay highly aroused for quite a while without coming. When you feel yourself approaching your point of no return, simply back off a bit, stroke yourself more gently or not at all, and stay aroused without ejaculating. Then as you feel yourself getting a little distance from your point of no return, return to more vigorous self-stimulation. Repeat this several times over several sessions. Approach your point of no return, then back off. For most men, it doesn’t take long to develop good ejaculatory control while alone.

Then move on to masturbation with a lubricated hand. Use saliva, vegetable oil, or a commercial sexual lubricant. For most people, lubricants increase the sensual intensity of erotic fondling. Follow the same program: Masturbate until you approach your point of no return, then back off. Repeat this several times over several sessions.

Once you have good control during masturbation, and appreciate whole-body sensuality, and feel comfortable breathing deeply during lovemaking, then you’re ready for the couples program — if you’re in a couple. The couple approach is called the “Stop-Start Technique.” First, arrange “stop” and “start” signals with your lover, for example, a light pinch or tap, or a tug on an ear.

Then, your lover strokes your penis by hand as you lie still. When you approach your point of no return, give the “stop” signal. Your lover immediately stops stroking you and simply holds your penis gently, as you continue to breathe deeply and pays close attention to the sensations you’re feeling. When you no longer feels close to ejaculation, gives the “start” signal, and your lover begins stroking you again. How many stops and starts should you do? A half-dozen over a 15-minute period works well for most couples. Do what feels comfortable for you.

With stop-start, the focus is on the man. He’s the one learning the new skill. But don’t forget the woman’s sensual needs. As part of each practice session, she might guide your hand over her to show you what she likes.

Once you’ve gained good ejaculatory control with your lover’s hand, try the same stop-start procedure with oral caresses. Again, you begin by lying still.

Once you’ve gained good control orally, feel free to start moving. You’re making love again — but now you have ejaculatory control. Congratulations.

Here are some other suggestions for lasting longer:

The man-on-top (missionary) position can be fun, but it’s harder for most men to control their ejaculatory timing, because they have to hold themselves up. Try making love with the woman on top. This position is more relaxing for men, and it often helps ejaculatory control.

Make some noise. Love moans help men (and women) relax, and they often help men last longer.

It’s important to understand that learning ejaculatory control takes time and practice. You may feel a little awkward along the way. Try to maintain a sense of humor about any accidental spills.

Some penile skin creams advertise that they help a man last longer. These products contain topical anesthetics that dull sensation in the penis. If you like to play with penile sensation, there’s no harm in using them. But they’re not a good idea for learning to last longer. They dull sensation. But the key to lasting longer is for the man to become more familiar with what he feels so he can back off from his point of no return while still remaining highly aroused.

Finally, the program we recommend for learning ejaculatory control is very likely to provide your lover with greater sexual enjoyment — but not just because you last longer. Women generally prefer leisurely, playful, whole-body, massage-oriented sensuality that includes the genitals but is not limited to them. Women’s main complaints about men’s sexual style are that it’s too rushed, too mechanical, too eager for intercourse, and that it focuses only on the breasts and genitals. Women generally feel that the whole body is a sensual playground and can’t understand why so many men explore only a few corners of it. Like women, penises generally prefer leisurely, playful, whole-body, massage-oriented lovemaking. The rushed, penis-centered, intercourse-fixated sex style puts a lot of pressure on the penis, and leads to premature ejaculation. But when men make love the way women prefer, whole-body arousal takes the pressure off your penis and you last longer. Basically, if men would make love the way women prefer, women would have fewer complaints, and men would have fewer sex problems.

Treatment

Pure herbal treatment by Dr & Hakeem Tariq Mehmood Taseer to cure premature ejaculation problem in males with well proven results. Has a very high success rate in treating different causes of this problem. Dosage and duration of the treatment may vary as per the patient profile. Treatment is without any side effect.

Erectile Dysfunction

Erectile dysfunction, sometimes called “impotence,” is the repeated inability to get or keep an erection firm enough for sexual intercourse. The word “impotence” may also be used to describe other problems that interfere with sexual intercourse and reproduction, such as lack of sexual desire and problems with ejaculation or orgasm. Using the term erectile dysfunction makes it clear that those other problems are not involved.

Erectile dysfunction, or ED, can be a total inability to achieve erection, an inconsistent ability to do so, or a tendency to sustain only brief erections. These variations make defining ED and estimating its incidence difficult. Estimates range from 15 million to 30 million, depending on the definition used. According to the National Ambulatory Medical Care Survey (NAMCS), for every 1,000 men in the United States, 7.7 physician office visits were made for ED in 1985. By 1999, that rate had nearly tripled to 22.3. The increase happened gradually, presumably as treatments such as vacuum devices and inject able drugs became more widely available and discussing erectile function became accepted. Perhaps the most publicized advance was the introduction of the oral drug sildenafil citrate (Viagra) in March 1998. NAMCS data on new drugs show an estimated 2.6 million mentions of Viagra at physician office visits in 1999, and one-third of those mentions occurred during visits for a diagnosis other than ED.

In older men, ED usually has a physical cause, such as disease, injury, or side effects of drugs. Any disorder that causes injury to the nerves or impairs blood flow in the penis has the potential to cause ED. Incidence increases with age: About 5 percent of 40-year-old men and between 15 and 25 percent of 65-year-old men experience ED. But it is not an inevitable part of aging.

Definition

Erectile dysfunction (ED) is the inability of a man to maintain a firm erection long enough to have sex. Although erectile dysfunction is more common in older men, this common problem can occur at any age. Having trouble maintaining an erection from time to time isn’t necessarily a cause for concern. But if the problem is ongoing, it can cause stress and relationship problems and affect self-esteem.

Formerly called impotence, erectile dysfunction was once a taboo subject. It was considered a psychological issue or a natural consequence of growing older. These attitudes have changed in recent years. It’s now known that erectile dysfunction is more often caused by physical problems than by psychological ones, and that many men have normal erections into their 80s.

Although it can be embarrassing to talk with your doctor about sexual issues, seeking help for erectile dysfunction can be worth the effort. Erectile dysfunction treatments ranging from medications to surgery can help restore sexual function for most men. Sometimes erectile dysfunction is caused by an underlying condition such as heart disease. So it’s important to take erectile trouble seriously because it can be a sign of a more serious health problem.

How Does an Erection Occur?

The penis contains two chambers called the corpora cavernosa, which run the length of the organ (see figure 1). A spongy tissue fills the chambers. The corpora cavernosa are surrounded by a membrane, called the tunica albuginea. The spongy tissue contains smooth muscles, fibrous tissues, spaces, veins, and arteries. The urethra, which is the channel for urine and ejaculate, runs along the underside of the corpora cavernosa and is surrounded by the corpus spongiosum.

Erection begins with sensory or mental stimulation, or both. Impulses from the brain and local nerves cause the muscles of the corpora cavernosa to relax, allowing blood to flow in and fill the spaces. The blood creates pressure in the corpora cavernosa, making the penis expand. The tunica albuginea helps trap the blood in the corpora cavernosa, thereby sustaining erection. When muscles in the penis contract to stop the inflow of blood and open outflow channels, erection is reversed.

Causes

Male sexual arousal is a complex process involving the brain, hormones, emotions, nerves, muscles and blood vessels. If something affects any of these systems or the delicate balance among them erectile dysfunction can result.

Anatomy of an Erection

The penis contains two cylindrical, sponge-like structures (corpus cavernosum) that run along its length, parallel to the tube that carries semen and urine (urethra).

When a man becomes sexually aroused, nerve impulses cause the blood flow to the cylinders to increase several times the normal amount. This sudden influx of blood expands the sponge-like structures and produces an erection by straightening and stiffening the penis.

Continued sexual arousal maintains the higher rate of blood flow into the penis and limits the blood flow out of the penis, keeping the penis firm. After ejaculation or when the sexual excitement passes, the excess blood drains out of the spongy tissue, and the penis returns to its non erect size and shape.

Physical Causes of Erectile Dysfunction

At one time, doctors thought erectile dysfunction was primarily caused by psychological issues. But this isn’t true.

While thoughts and emotions always play a role in getting an erection, erectile dysfunction is usually caused by something physical, such as a chronic health problem or the side effects of a medication. Sometimes a combination of things causes erectile dysfunction.

Common Causes of Erectile Dysfunction Include:

Heart disease

Clogged blood vessels (atherosclerosis)

High blood pressure

Diabetes

Obesity

Metabolic syndrome

Other causes of erectile dysfunction include:

Certain prescription medications

Tobacco use

Alcoholism and other forms of drug abuse

Treatments for prostate cancer

Parkinson’s disease

Multiple sclerosis

Hormonal disorders such as low testosterone (hypogonadism)

Peyronie’s disease

Surgeries or injuries that affect the pelvic area or spinal cord

In some cases, erectile dysfunction is one of the first signs of an underlying medical problem.

Psychological Causes of Erectile Dysfunction

The brain plays a key role in triggering the series of physical events that cause an erection, beginning with feelings of sexual excitement. A number of things can interfere with sexual feelings and lead to or worsen erectile dysfunction. These can include:

Depression

Anxiety

Stress

Fatigue

Poor communication or conflict with your partner

The physical and psychological causes of erectile dysfunction interact. For instance, a minor physical problem that slows sexual response may cause anxiety about maintaining an erection. The resulting anxiety can worsen erectile dysfunction.

Risk Factors

A variety of risk factors can contribute to erectile dysfunction. They include:

Getting older. As many as 80 percent of men 75 and older have erectile dysfunction. Many men begin to notice changes in sexual function as they get older. Erections may take longer to develop, may not be as rigid or may take more direct touch to the penis to occur. But erectile dysfunction isn’t an inevitable consequence of normal aging. Erectile dysfunction often occurs in older men mainly because they’re more likely to have underlying health conditions or take medications that interfere with erectile function.

Having a chronic health condition. Diseases of the lungs, liver, kidneys, heart, nerves, arteries or veins can lead to erectile dysfunction. So can endocrine system disorders, particularly diabetes. The accumulation of deposits (plaques) in your arteries (atherosclerosis) also can prevent adequate blood from entering your penis. And in some men, erectile dysfunction may be caused by low levels of testosterone (male hypogonadism)

Taking certain medications. A wide range of drugs — including antidepressants, antihistamines and medications to treat high blood pressure, pain and prostate cancer — can cause erectile dysfunction by interfering with nerve impulses or blood flow to the penis. Tranquilizers and sleeping aids also can pose a problem.

Certain surgeries or injuries. Damage to the nerves that control erections can cause erectile dysfunction. This damage can occur if you injure your pelvic area or spinal cord. Surgery to treat bladder, rectal or prostate cancer can increase your risk of erectile dysfunction.

Substance abuse. Chronic use of alcohol, marijuana or other drugs often causes erectile dysfunction and decreased sexual drive.

Stress, anxiety or depression. Other psychological conditions also contribute to some cases of erectile dysfunction.

Smoking. Smoking can cause erectile dysfunction because it restricts blood flow to veins and arteries. Men who smoke cigarettes are much more likely to develop erectile dysfunction.

Obesity. Men who are obese are much more likely to have erectile dysfunction than are men at a normal weight.

Metabolic syndrome. This syndrome is characterized by belly fat, unhealthy cholesterol and triglyceride levels, high blood pressure, and insulin resistance.

Prolonged bicycling. Over an extended period, pressure from a bicycle seat has been shown to compress nerves and blood flow to the penis, leading to temporary erectile dysfunction and penile numbness.

Symptoms

Erectile dysfunction is the inability to maintain an erection sufficient for sexual intercourse at least 25 percent of the time.

An occasional inability to maintain an erection happens to most men and is normal. But ongoing erection problems are a sign of erectile dysfunction and should be evaluated. In some cases, erectile dysfunction is the first sign of another underlying health condition that needs treatment.

Prevention

Although most men experience episodes of erectile dysfunction from time to time, you can take these steps to decrease the likelihood of occurrences:

Work with your doctor to manage conditions that can lead to erectile dysfunction, such as diabetes and heart disease.

Limit or avoid the use of alcohol.

Avoid illegal drugs such as marijuana.

Stop smoking.

Exercise regularly.

Reduce stress.

Get enough sleep.

Get help for anxiety or depression.

See your doctor for regular checkups and medical screening tests.

Diagnosis

A medical examination may indicate neurological, vascular, or hormonal disease, or Peyronie’s disease. History of illness, smoking, drug use, and hypertension can be ascertained with a thorough examination of health history.

Laboratory tests are performed to identify the underlying cause.

Blood Tests and Urinalysis

Blood tests can indicate conditions that may interfere with normal erectile function. These tests measure hormone levels, cholesterol, blood sugar, liver and kidney function, and thyroid function. Excess prolactin (hyperprolactinemea) can lower testosterone levels, which can diminish libido. Both of these levels are measured, as well as levels of other sex hormones. If they are persistently low, an endocrinologist (hormone specialist) should be consulted.

CBC. Complete blood count (CBC) of red cells and white cells is used to evaluate the presence of anemia. A low level of red cells limits the body’s utilization of oxygen and can lead to fatigue and general malaise. The level of blood lipids (fats) such as cholesterol and triglycerides may indicate arteriosclerosis, which can reduce blood flow to the penis.

Tests that assess erectile function examine the blood vessels, nerves, muscles, and other tissues of the penis and pelvic region.

Duplex ultrasound. Duplex ultrasound is used to evaluate blood flow, venous leak, signs of artherosclerosis, and scarring or calcification of erectile tissue. Erection is induced by injecting prostaglandin, a hormone-like stimulator produced in the body. Ultrasound is then used to see vascular dilation and measure penile blood pressure (which may also be measured with a special cuff). Measurements are compared to those taken when the penis is flaccid.

Prostate examination. An enlarged prostate, which can be detected with a digital rectal examination (DRE), can interfere with blood flow and nerve impulses in the penis.

Penile nerve function. Tests such as the bulbocavernosus reflex test are used to determine if there is sufficient nerve sensation in the penis. The physician squeezes the glans (head) of the penis, which immediately causes the anus to contract if nerve function is normal. A physician measures the latency between squeeze and contraction by observing the anal sphincter or by feeling it with a gloved finger inserted past the anus. Specific nerve tests are used in patients with suspected nerve damage as a result of diabetes or nerve disease.

Nocturnal penile tumescence (NPT). It is normal for a man to have five to six erections during sleep, especially during rapid eye movement (REM). These erections occur about every 90 minutes and last for about 30 minutes. Their absence may indicate a problem with nerve function or blood supply in the penis. There are two methods for measuring changes in penile rigidity and circumference during nocturnal erection: snap gauge and strain gauge.

Snap gauge. Involves wrapping three plastic bands of varying strength around the penis. Erectile function is assessed according to which bands break. Strain gauge involves placing special elastic bands at the base and tip of the penis. These bands stretch during erection and register changes in circumference.

Penile biothesiometry. This test uses electromagnetic vibration to evaluate sensitivity and nerve function in the glands and shaft of the penis. A decreased perception of vibration may indicate nerve damage in the pelvic area, which can lead to impotence.

Vasoactive injection. When injected into the penis, certain solutions cause erection by dilating blood vessels in erectile tissue. Normally, these injections produce an erection lasting about 20 minutes. During this procedure, penile pressure is measured and x-rays may be taken of the penile blood vessels using a special dye (contrast agent).

Effects

Whether the cause of impotence is physiological or psychological, both the patient and his partner often experience a range of intense feelings and emotions. Any of these feelings can lead to a sense of hopelessness and lower self-esteem.

Of course, feelings of sexual insecurity can reinforce any performance anxiety a man experiences and create a vicious cycle of repeated failures and increasingly negative feelings.

The first step to overcoming these feelings is to acknowledge the problem and communicate honestly and openly with each other.

Self Esteem

Because sexual performance is often a big part of a man’s self-esteem, experiencing erectile dysfunction (ED) can be devastating not only to a man’s sex life, but to his entire sense of being. Men with ED can become uncertain of themselves and avoid intimate situations with their partners; this only increases the pressure and anxiety associated with a condition which is often treatable.

In addition, erectile dysfunction can cause men to feel inadequate in their roles. Men who are suffering from ED tend to isolate themselves from their relationships and withdraw from their partners.

The psychological effects of ED can invade every aspect of a man’s life, from his relationship with his partner, to his interactions on a social level, to his job performance. Therefore, it is important for a man who is suffering from ED to feel as comfortable as possible discussing his condition with his partner, and with his physician, in order to discover the treatment strategy which can best help overcome this condition.

Partners

Erectile dysfunction can be embarrassing to discuss not only with a health care provider but with also with a partner. It often causes men to withdraw from those who care about them, which puts a serious strain on relationships.

Partners of men with ED feel that initiating a discussion regarding the situation will cause embarrassment and humiliation. They also may develop a sense of inadequacy, thinking the cause of ED is their fault and that they are no longer physically attractive to their partner.

In most cases, ED is a result of physical causes (although it can easily be made worse by psychological factors), and can often be treated. However, silence, embarrassment, and feelings of inadequacy and humiliation only lead to further withdrawal on the part of both partners, increasing the distance and tension within the relationship. The anxiety which results can easily make a case of ED worse, leading to a vicious circle of failure and anxiety about failure.

Both partners and men with ED need to try to remember that ED is most often a treatable physical condition. The first step to treatment, however, is trust and a willingness on the part of both partners to discuss the situation with each other, and with a physician.

Treatment

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Testicular Problems and Infertility

Testicular failure is one condition that may affect sperm health and lead to male infertility. There are different forms of testicular failure that may affect the male reproductive system and a variety of causes that may contribute to testicular failure.

All of these factors may result in different conditions affecting sperm health. However, there are several infertility treatment options available to help relieve the symptoms of testicular failure and increase a coupleï¿½s odds of getting pregnant.

What is Testicular Failure?

Testicular failure is a general term describing a condition in which the testicles do not properly produce sperm or hormones. However, there are a number of underlying male fertility problems that may be diagnosed as the cause of testicular failure. The following are some conditions that may be affecting male fertility and contributing to testicular failure:

Chromosomal abnormalities

Testicular trauma

Testicular torsion (twisting)

Diseases or infections such as mumps, orchitis or testicular cancer

Undescended testicles at birth

Problems involving sexual maturation

Certain drugs or medications such as steroids or marijuana

Lifestyle factors

Lifestyle factors may affect testicular functioning and prevent the testicles from maintaining normal functions. Activities such as riding a motorcycle, for example, can increase the risk of testicular or scrotum injury.

When testicular failure results in the inability to produce proper levels of male hormones, the condition will likely lead to a diagnosis of hypogonadism.

Testicular Failure Symptoms

Signs and symptoms of testicular failure may include the following:

Low or lack of sex drive

Infertility

Delayed puberty

Decrease in height

Enlarged breasts (gynecomastia)

Lack of muscle mass

Hair loss (usually in the underarms or pubic areas)

Infrequent need to shave

Small testicles

Presence of a tumor or mass near the testes

In addition, during examination, decreases in bone density or the presence of bone fractures may be noted as well as low levels of testosterone hormones accompanied by high levels of FSH and LH.

Testicular Failure and Sperm Health

Testicular failure is associated with three main fertility problems that may affect sperm health. These male fertility problems include the following:

Azoospermia: this condition results from an absence of the cells necessary to help sperm divide and is also known as sertoli cell-only syndrome

Maturation Problems: this refers to a condition in which sperm production begins normally, but is interrupted at some point during development. The resulting sperm that is present in the ejaculate will thus not be fully developed

Hypospermatogeneses: this refers to a condition in which few or no sperm are present in the ejaculate as a result of low sperm production

Testicular Failure Diagnosis

Diagnosing testicular failure may involve a variety of male fertility testing procedures. Congenital testicular failure will typically be indicated by the presence of “ambiguous” genitalia at birth.

Fertility tests for the diagnosis of testicular failure may include the following:

Testicle Problems

Epididymitis

An inflammation of the epididymis, the tube that transports sperm from the testicle towards the penis.

If the swelling affects the testicle as well as the epididymis, the condition is known as epididymo-orchitis.

What are the main symptoms?

Severe pain in the scrotum

A swollen area that may feel hot to the touch

Fever

What’s the risk?

It’s unusual, although it’s more common in childhood and has a peak occurrence in adolescence.

What causes it?

In adults the condition may follow a viral or bacterial infection. Bacteria can sometimes find their way to the epididymis as a consequence of infection with the common bacteria that cause urinary infections or by other organisms such as those of chlamydia or gonorrhoea. Epididymitis can sometimes follow a vasectomy.

How can I prevent it?

The risk of epididymitis being caused as a result of a sexually transmitted infection (STI) can be reduced by always practising safer sex (i.e. using a condom during intercourse) and having regular check-ups for STIs at a GUM (genito-urinary medicine) clinic.

Should I see a doctor?

Yes. A urine test can diagnose the condition. Your doctor will make the diagnosis and exclude other potentially important conditions.

How can I help myself?

Follow your doctor’s orders and be patient ï¿½ epididymitis can take several months to clear up completely.

What’s the outlook?

Good, although sometimes the scrotum remains somewhat enlarged.

Hydrocele

What is it?

A swelling in the scrotum, caused by a harmless build-up of fluid within the sacs surrounding the testicles.

What are the main symptoms?

A soft and usually painless swelling of the scrotum. Sometimes the swelling can be as large as a grapefruit.

What’s the risk?

Low.

What causes it?

A build-up of fluid in the scrotum, sometimes caused by an injury to the testicles or following infection or inflammation.

How can I prevent it?

It’s not easy to prevent, except by protecting the testicles during sport or potentially risky work.

Should I see a doctor?

Yes. It’s important to rule out any more serious conditions.

The doctor will examine the testicles. He or she may also shine a light through the scrotum ï¿½ if the light passes through, it’s probably a hydrocele.

How can I help myself?

There’s not much you can do.

What’s the outlook?

Most serious cases can be permanently treated.

Testicular Cancer

What is it?

A relatively rare cancer that usually affects one testicle.

What are the main symptoms?

The key symptoms to look out for are:

A lump in either testicle

Any enlargement of the testicle

A feeling of heaviness in the scrotum

A dull ache in the abdomen or groin

A sudden collection of fluid in the scrotum

Enlargement or tenderness of the breasts

It’s important to remember that testicular cancer may not cause any discomfort or pain, especially in the early stages. The most common symptom is a small painless lump.

Any of these symptoms can also have benign (i.e. non-cancerous) causes, but they should always be checked by a doctor.

As some of these symptoms aren’t always obvious, it’s important to check your testicles regularly.

What’s the risk?

Testicular cancer is the most common cancer affecting men aged 20ï¿½35 but the lifetime risk of developing the disease is still only 1 in 400. That compares with 1 in 12 for lung cancer and for prostate cancer. However, the incidence of testicular cancer is increasing ï¿½ in fact, it’s doubled in the past 20 years.

The risks are greater (1 in 44) for men who were born with undescended testicles. Men with a brother or father who had a testicular tumour have a 6ï¿½10 times higher risk of developing this cancer.

What causes it?

The causes aren’t yet fully understood. However, the fact that men who develop testicular cancer are more likely to have had undescended testicles, and to be affected by fertility problems, suggests some sort of common cause.

One plausible theory, not yet fully proven, is that testicular tissues are damaged while male foetuses are still developing, possibly as a result of their mothers’ exposure to environmental pollutants which are chemically similar to the female hormone oestrogen. It may be that male foetuses are being over-exposed to oestrogen and that, as a result, some develop a range of problems with their reproductive systems.

Some studies have also linked testicular cancer to a sedentary lifestyle in boys, although further research is needed to confirm this.

How can I prevent it?

You can’t.

Should I see a doctor?

If you have any of the symptoms listed above you should see your doctor as soon as possible.

Your doctor will examine your testicles and, if he or she suspects a problem, you’ll probably be referred to a specialist doctor (normally a urologist). Your testicles will be examined again and you may be asked to have an ultrasound (a painless procedure) and a blood test.

How can I help myself?

Inform yourself about your condition and its treatment. Talk to your doctor; contact cancer organisations; read material on the Internet (although with care ï¿½ not all of it is accurate).

Accept that it’s inevitable that you’ll feel anxious and scared. However, it’s also important to remember that testicular cancer is one of the easiest cancers to treat successfully.

Consider ways in which you can reduce your stress, such as counselling, meditation, yoga and relaxation exercises.

If it feels right, join a cancer support group. Your hospital or a cancer organisation can give you details of groups that might be suitable for you.

What’s the outlook?

Generally very good indeed. If diagnosed early, 96% of patients can be cured completely. Even when the cancer has spread, up to 80% of men can still be cured.

Torsion

What is it?

Each testicle is suspended within the scrotum by the spermatic cord.

This can become twisted, cutting off the blood supply to a testicle.

What are the main symptoms?

Sudden, very severe pain in a testicle

Swelling

Nausea and vomiting

Fever

What’s the risk?

Low. It’s most common in teenage boys.

What causes it?

Many cases have no known or obvious cause, although it can be linked to physical activity. Some men, who have naturally more mobile testicles, are at higher risk.

How can I prevent it?

You can’t.

Should I see a doctor?

Definitely. In fact, torsion is a medical emergency ï¿½ aside from the pain, if the spermatic cord is twisted for more than a few hours a testicle can die due a lack of blood supply, and will then have to be removed.

How can I help myself?

There’s not much you can do.

What’s the outlook?

Good, if treatment is carried out promptly.

Varicocele

What is it?

Essentially a varicose vein within the testicle.

What are the main symptoms?

Varicoceles are often painless and almost always located on the left testicle.

There can be a swelling that is often described as feeling like a warm tangle of worms. This is usually more noticeable when you stand up.

There may be a “dragging feeling” in the testicle.

Fertility problems. It’s thought that the accumulation of blood overheats the testicle and affects sperm production, although not all men with a varicocele are infertile.

What’s the risk?

Approximately 10ï¿½15% of men develop a varicocele.

What causes it?

A damaged valve in the vein draining blood from the testicle.

How can I prevent it?

You can’t.

Should I see a doctor?

Yes. It’s important to rule out any more serious conditions.

Varicoceles can usually be diagnosed through manual examination. A doctor may also shine a light through the testicle ï¿½ a varicocele will block out the light. Small varicoceles can sometimes be diagnosed by ultrasound.

How can I help myself?

There’s not much you can do.

What’s the outlook?

Good, but varicoceles can sometimes recur. The treatment of varicoceles can result in a significant increase in fertility: improvements in semen quality occur in 50ï¿½90% of men.

Treatment

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Low Testosterone

Male Hypogonadism

All men undergoing fertility testing will be checked for hormonal imbalances that could be contributing to their infertility. One important hormone necessary for proper sexual functioning in men is testosterone.

When a man is found to have a testosterone deficiency, it can signal a common disorder known as hypogonadism.

Definition

Male hypogonadism is a condition in which the body doesn’t produce enough of the sex hormone testosterone. As many as 5 million men in the United Sates may not produce enough testosterone — the hormone that plays a key role in masculine growth and development during puberty.

Testosterone’s effects begin after conception, stimulating the formation of male sex organs. The hormone continues to play an important role through puberty and adulthood by triggering male characteristics and maintaining sex drive.

You may be born with hypogonadism, or it can develop later in life from injury or infection. The effects — and what you can do about them — depend on the cause and at what point in your life hypogonadism occurs.

During fetal development, low testosterone can cause incomplete formation of sex organs. Low testosterone levels before puberty can permanently affect growth and development. After puberty, the development of hypogonadism is more likely to cause temporary problems that may improve with treatment. Some types of hypogonadism can be treated with testosterone replacement therapy.

What Does Testosterone Do?

Testosterone, often referred to as the male hormone although females do produce small amounts of the hormone as well, is a hormone that is produced in the testicles. It is responsible for the growth and development of the sex and reproductive organs in men. Additionally, testosterone contributes to the deepening of a man’s voice during puberty, fat distribution, and bone mass. Testosterone also helps to keep a man’s energy levels up as well as encourage his sex drive and fertility.

Much like women, whose production of estrogen and progesterone taper off as they age, testosterone levels begin to decline as a man gets older. These naturally-occurring low testosterone levels can contribute to a decreased sex drive in older men. Yet, low testosterone levels earlier in life are not natural and can produce many unwanted physical changes, including infertility. A common culprit for these falling testosterone levels: hypogonadism.

Symptoms

Hypogonadism can occur during fetal development, puberty or adulthood. Depending on when it develops, the signs and symptoms differ.

Fetal Development

If the body doesn’t produce enough testosterone during fetal development, growth of external sex organs may be impaired.

Depending at when it develops, and how much testosterone is present, a child that is genetically male may be born with:

Female genitals

Ambiguous genitals (genitals that are neither clearly male or female)

Underdeveloped male genitals

Puberty

During puberty, male hypogonadism may slow growth and affect development.

It can cause:

Decreased development of muscle mass

Lack of deepening of the voice

Impaired growth of body hair

Impaired growth of the penis and testicles

Excessive growth of the arms and legs in relation to the trunk of the body

Hypogonadism can also cause mental and emotional changes. As testosterone decreases, some men may experience symptoms similar to those of menopause in women. These may include:

Fatigue

Decreased sex drive

Difficulty concentrating

Hot flashes

Irritability

Depression

Causes

Testosterone Binding

Male hypogonadism means the testicles don’t produce enough of the male sex hormone testosterone. There are two basic types of hypogonadism:

Primary. This type of hypogonadism — also known as primary testicular failure — originates from a problem in the testicles.

Secondary. This type of hypogonadism indicates a problem in the hypothalamus or the pituitary gland — parts of the brain that signal the testicles to produce testosterone. The hypothalamus produces gonadotropin-releasing hormone, which signals the pituitary gland to make follicle-stimulating hormone (FSH) and luteinizing hormone. Luteinizing hormone then signals the testes to produce testosterone.

Either type of hypogonadism may be caused by an inherited (congenital) trait or something that happens later in life, such as an injury or an infection (acquired).

Primary Hypogonadism

Common causes of primary hypogonadism include:

Klinefelter ‘s Syndrome This condition results from a congenital abnormality of the sex chromosomes, X and Y. A male normally has only one X and one Y chromosome. In Klinefelter’s syndrome, two or more X chromosomes are present in addition to one Y chromosome. The Y chromosome contains the genetic material that determines the sex of a child and related development. The extra X chromosome that occurs in Klinefelter’s syndrome causes abnormal development of the testicles, which in turn results in underproduction of testosterone.

Undescended Testicles Before birth, the testicles develop inside the abdomen and normally move down into their permanent place in the scrotum two months before birth. One or both of the testicles may not be descended at birth. This condition often corrects itself within the first few years of life without treatment. If not corrected in early childhood, it may lead to malfunction of the testicles and reduced production of testosterone.

Mumps Orchitis If a mumps infection involving the testicles in addition to the salivary glands (mumps orchitis) occurs during adolescence or adulthood, long-term testicular damage may occur. This may affect normal testicular function and testosterone production.

Injury to the testicles. Because of their location outside the abdomen, the testicles are prone to injury. Damage to normally developed testicles can cause hypogonadism. Damage to one testicle may not impair testosterone production.

Cancer Treatment Chemotherapy or radiation therapy for the treatment of cancer can interfere with testosterone and sperm production. The effects of both treatments often are temporary, but permanent infertility may occur. Although many men regain their fertility within a few months after treatment ends, preserving sperm before starting cancer therapy is an option that many men consider.

Normal Aging Older men generally have lower testosterone levels than younger men do. As men age, there’s a slow and continuous decrease in testosterone production. The rate that testosterone declines varies greatly among men. As many as 30 percent of men older than 75 have a testosterone level that’s below normal.

Secondary Hypogonadism

In Secondary Hypogonadism the testicles are normal but function improperly due to a problem with the pituitary or hypothalamus. A number of conditions can cause secondary hypogonadism, including:

Kallmann Syndrome Abnormal development of the hypothalamus — the area of the brain that controls the secretion of pituitary hormones — can cause hypogonadism. This abnormality is also associated with impaired development of the ability to smell anosmia.

Pituitary Disorders An abnormality in the pituitary gland can impair the release of hormones from the pituitary gland to the testicles, affecting normal testosterone production. A pituitary tumor or other type of brain tumor located near the pituitary gland may cause testosterone or other hormone deficiencies. Also, the treatment for a brain tumor such as surgery or radiation therapy may impair pituitary function and cause hypogonadism.

Tests And Diagnosis

Your doctor may test your blood level of testosterone if you have any of the signs or symptoms of hypogonadism. Early detection in boys can help prevent problems from delayed puberty. Early diagnosis and treatment in men offers better protection against osteoporosis and other related conditions.

Doctors base a diagnosis of hypogonadism on symptoms and results of blood tests that measure testosterone levels. Because testosterone levels vary and are generally highest in the morning, blood testing is usually done early in the day.

If tests confirm you have low testosterone, further testing can determine if a testicular disorder or a pituitary abnormality is the cause. Based on specific signs and symptoms, additional studies can pinpoint the cause. These studies may include:

Hormone testing

Semen analysis

Pituitary imaging

Genetic studies

Testicular biopsy

Testosterone testing also plays an important role in managing hypogonadism. This helps your doctor determine the right dosage of medication, both initially and over time.

Treatment

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Varicocele

A fairly common infertility problem resulting in male fertility problems, varicocele refers to the presence of varicose veins in the testicles. This condition is thought to affect 15% of the general male population but as much as 40% of all infertile males. Varicoceles tends to occur more often in men experiencing secondary infertility.

Definition

A varicocele is an enlargement of the veins within the scrotum, the loose bag of skin that holds your testicles. A varicocele is similar to a varicose vein that can occur in your leg.

About one in six men have a varicocele. For males who are infertile, the figure is higher ï¿½ about 40 percent. Varicoceles are the most common cause of low sperm production and decreased sperm quality, although not all varicoceles affect sperm production.

Most varicoceles develop over time. Fortunately, most varicoceles are easy to diagnose and, if they cause symptoms, can be repaired surgically.

A varicocele is a dilation of the pampiniform plexus – the veins that drain blood from the testicle. Due to anatomical differences, varicoceles are more common on the left side although they may also occur on both sides simultaneously. As the varicose veins dilate, the valves within the veins become incompetent and no longer function. This allows blood flow to reverse within the veins which causes abnormal blood flow around the testicle. It is this change in blood flow which leads to poor testicular function by causing overheating of the testicle.

How Does Varicocele Affect Fertility?

As with most other varicose veins, varicoceles occurs when blood in the testicles does not circulate out properly. As a result, this excess blood causes the temperature in the testicles to rise leading to abnormal testosterone levels. This increased temperature in the scrotum then prevents the proper production and maturation of sperm thereby lowering a manï¿½s fertility.

Although it is possible for varicocele to affect both testicles, about 90% of the time it is just the left side that is affected. While experts arenï¿½t exactly sure why it is almost always the left testicle that develops the varicose veins, the fact that there are 40% fewer valves in the left spermatic vein, which is also as much as 8 to 10 centimeters longer than the spermatic cord in the right testicle, is one possible reason. Additionally, the left spermatic vein has more pressure placed on it than the right, which may cause it to be more prone to blockages.

Varicoceles Symptoms

Often times, men affected by varicocele will not produce any visible signs. On occasion, though, a man may experience one or more of the symptoms associated with varicocele, which can include:

Testicular pain or discomfort

Noticeable shrinkage of the testicle(s)

A heavy feeling in the testicle

Infertility

An enlarged vein that can be found by touch or sight

Causes

The spermatic cord, which supplies blood to and returns blood from the testicle, houses the vas deferens, which carries sperm from the testicles. The pampiniform plexus is a group of veins within the scrotum and above the testicles. The pampiniform plexus drains blood from the testicles. Enlargement of these veins often occurs during puberty.

It’s not certain what causes varicoceles, but many experts believe abnormal valves within the veins prevent normal blood flow. The resulting backup causes the veins to widen (dilate).

Varicoceles usually occur in the region of the left testicle, most likely because of the position of the left testicular vein. However, a varicocele in one testicle can affect sperm production in both testicles.

Veins that have become significantly enlarged will likely be visible. However, small or medium sized veins may only be identifiable through touch.

How does a varicocele cause infertility?

We are certain that varicoceles decrease fertility but we have not yet categorically determined why this is so. There are several theories:

A) Increased temperature of the testicles

The testicles are located in the scrotum, which effectively regulates their temperature. They are maintained at a temperature slightly below body temperature. (This is probably why they are located outside the body rather than inside the body where they clearly would be better protected.) In cold weather you may notice that a man’s testicles move close into his body as the cremasteric muscles, the muscles in the scrotum wall, tighten. In warm weather the cremasteric muscles relax and lengthen allowing the testicles to hang away from a man’s body and cool down.

Some babies are born without their testicles having descended into their scrotum. They are trapped somewhere in their bodies and constantly exposed to body temperature. This is so harmful for the testicles that if they remain there past puberty they will stop producing sperm altogether and have a higher chance of developing cancer. Therefore if a boy’s testicles do not descend into the scrotum by the time he is 12 months old, they should be surgically brought down and placed into the scrotum.

Varicoceles are a group of dilated veins filled with blood, which surround the testicles. The blood is at body temperature and if the testes are near these veins they will be kept at a higher temperature than is beneficial for them. Even if a man has a varicocele only on one side, the whole scrotum is warmed by the blood and both testicles can be negatively affected.

In general, larger testicles make more sperm than smaller testicles. Often however, you see men who have a large one-sided varicocele that has damaged the testis on one side making it smaller. The small teste makes significantly less sperm than the normal one. However even in the “normal” one the sperm quality is often very low. The varicocele is not only damaging the teste on the side where it is found but also suppressing the sperm production on the opposite (better) side.

When a varicocele is repaired the blood is no longer able to flow back into the scrotum. This affects not only the testes on that side, but also the opposite side with this normalization of temperature, there may be some dramatic improvement in sperm production. This improvement is most likely mostly coming from improved production in the larger better testicle.

B) Increased waste products back-flowing into the testicle

The veins draining the testicles connect into larger veins. On the left side, they drain into the kidney vein, which is draining blood from the kidney.

The blood from the kidney carries waste products, which may then drain backwards into the scrotum and collect there. This may negatively effect sperm production.

Diagnosing Varicocele

Many incidents of varicocele are diagnosed during physical examinations. However, in cases where varicoceles is suspected but none can be found by sight or touch, an ultrasound or venography (whereby dye is injected into the vein and then x-rayed) diagnostic test may be performed.

In some cases, a sperm analysis may also alert your fertility specialist to the presence of varicose veins in your testicles. Upon examination, a semen analysis can reveal sperm that is immature, damaged, has abnormal morphology or motility, is dying, or dead. It can also indicate decreased sperm count, another effect of varicocele.

Facts about Varicocele

A varicocele is a collection of enlarged, varicose veins that develops in the spermatic cord. Caused by a defective or damage valve that regulates blood flow into the main circulatory system. Blood flow is hampered and enlargement of the vein occurs.

A varicocele can occur in one or both testicles

Most common in the left testicle (85% more common)

More common in men between the ages of 15 and 25 years old (10-20% higher).

Varicocele, a Common Cause of Infertility

About 40% of infertile men have a varicocele.

About 80% of men with secondary infertility, who have fathered one child but are unable to do so again, have a varicocele.

Infertility is common because the blood carried in the dilated vein makes the testes warmer. It is this warmth damaging sperm that is believed to be the cause of infertility.

How does a varicocele affect semen quality?

The most common theory to explain how a varicocele affects semen quality has to do with overheating of the testicle. It is felt that the dilated veins allow warm blood from the abdominal cavity to flow around the testicle. This causes overheating of the testicle which then impairs its function. Commonly, a low sperm count, low motility, and abnormally shaped sperm (stress pattern) are found in men with varicoceles. A varicocele surrounding 1 testicle may affect the testicle on the opposite side of the body. A varicocele may also lead to testicular atrophy (impaired growth) and thus the testicle on the side of a varicocele may be smaller than its contralateral mate.

Nonsurgical Treatment for Male Infertility Caused by Varicoceles

Highly Effective, Widely Available Treatment is Underutilized

A varicocele is a varicose vein of the testicle and scrotum that may cause pain, testicular atrophy (shrinkage) or fertility problems. Veins contain one-way valves that work to allow blood to flow from the testicles and scrotum back to the heart.

When these valves fail, the blood pools and enlarges the veins around the testicle in the scrotum to cause a varicocele. Open surgical ligation, performed by a urologist, is the most common treatment for symptomatic varicoceles. Varicocele embolization, a nonsurgical treatment performed by an herbal physician, is as effective as surgery with less risk, less pain and less recovery time.

Prevalence

Approximately 10 percent of all men have varicoceles – among infertile couples, the incidence of varicoceles increases to 30 percent

Highest occurrence in men aged 15-35

As many as 70-80,000 men in America may undergo surgical correction of varicocele annually.

Treatment

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Infections And Infertility

What types of infection cause fertility problems?

Infection in the testes (orchitis) can damage the sperm-producing tubes (seminiferous tubules) and stop sperm production.

Infections in the reproductive tract caused by sexually transmitted infections, particularly untreated gonorrhoea, may cause blockages in the tail of the epididymis or other parts of the male genital tract.

Non-specific epididymo-orchitis or prostate infections may sometimes cause blockages along the reproductive tract.

Although an infection is often only temporary, severe damage can leave men permanently infertile. Mumps is the most common infection of the testes but is less likely to occur following the introduction of immunisation programs for children.

How does mumps cause infertility?

Mumps that spreads to the testes is called mumps orchitis. Mumps orchitis is the most well known infection of the testis and is caused by an infection with the mumps virus. Mumps orchitis does not always accompany mumps, but when it occurs after puberty can cause major swelling and pain.

It can also totally destroy the sperm-producing tubes (seminiferous tubules) and permanently stop sperm production. Mild cases of mumps orchitis may only stop sperm production for six to twelve months. Mumps vaccine is available and boys should be immunised in infancy to avoid infection and possible infertility in adult life.

How do sexually transmitted infections affect fertility?

Sexually transmitted infections, such as gonorrhoea, can damage or block the epididymis so that sperm cannot pass from the testis into the ejaculate.

Because the testis only contributes a small part to the ejaculate, these blockages do not obviously change the amount of fluid ejaculated but no sperm will be found in the ejaculate (azoospermia).

What is epididymo-orchitis?

Epididymo-orchitis is caused by viral or bacterial infections of the testes and epididymis. Pain and swelling usually last for several days.

Epididymo-orchitis sometimes happens with urinary tract infections and can cause permanent blockages to sperm transport and testicular damage but this is rare.

Early treatment with antibiotics is recommended to prevent testicular damage becoming too severe.

How do prostate infections cause infertility?

Since the ejaculatory duct passes through the prostate gland, infections of the prostate can cause swelling and block off part of the reproductive tract that passes through the prostate. This can also stop sperm from being ejaculated.

Because the prostate and seminal vesicles contribute most of the fluid to the ejaculate, a blockage near the prostate can sometimes reduce the volume of ejaculate. Infections of the prostate and seminal vesicles can also cause inflammatory cells to pass into the ejaculate, which may damage the sperm.

Very rarely, a man may have a congenital abnormality (a problem they have been born with) in which lumpy growths or ‘cysts’ in the prostate gland have formed. These cysts can also cause blockage of sperm at this level.

Can surgery repair blockages in the epididymis?

Some couples become pregnant naturally after surgery to remove blockages caused by infections. The success of surgery depends on the amount of damage and where the blockage is located in the reproductive tract.

Blockages near the testes (as in the epididymis) are particularly hard to fix because of the smaller size of the tube and difficulty in locating the site(s) of blockage. Sperm antibodies are also often a problem for men with these blockages and may also reduce the chance of natural pregnancy.

You should discuss with your surgeon what they believe your success rate might be for this type of procedure.

Can blockages in the prostate be treated?

Treatment of the infection in the prostate gland may remove the blockage and allow the flow of sperm again.

Sometimes surgery to remove cysts in the prostate is performed by inserting an operating telescope through the penis. Removal of the cyst by surgery can remove the blockage to sperm transport so that the man is able to achieve a pregnancy naturally following the surgery.

What are the risks with surgery?

All surgery, particularly where there is a general anaesthetic, has some risks that need to be discussed with the doctor.

The risks with these operations are small, however, sometimes bleeding and infection can develop at the site of the operation.

Are there other ways to treat sperm blockages?

In vitro fertilisation (IVF) or other forms of assisted reproduction may be performed if men wish to have a family and do not wish to have surgery, or surgery was unsuccessful, to remove the blockage. A biopsy, or sample of the testis, is taken to find sperm that can be used for ICSI/IVF procedures.

Most people assume that infections cause only temporary problems with their health. In fact, if an infection is not treated properly or quickly, it can cause serious problems throughout your body. And this includes your fertility.

What Type of Infection Will Affect My Fertility?

Almost any type of infection that makes an impact on your immune system can impair your fertility.

In particular, those that affect your reproductive tract, including the prostate, epididymis or the testis, can hinder your fertility. It is unlikely that an infection will impair your fertility so much as to make you sterile, though.

Most of the time, the effects of an infection are only temporary. While a pesky cold or some other type of infection may lower your sperm count or slow down your sperm’s motility, more often than not, your sperm will rebound back to normal in a few months.

Those That Damage

There are some infections, however, that can do serious damage if not looked after right away. Sexually transmitted diseases, or STDs, are the most common infection associated with male infertility. If they are left untreated, you are repeatedly infected, or have frequent flare-ups, scarring and blockage in the reproductive tracts can occur. Mycoplasma, an organism often found in sexually active men, can attach itself to sperm cells, thereby impeding motility.

Another illness that is often associated with male infertility is the mumps. Men who contract the mumps after puberty are at risk of developing fertility problems. This is because the illness can lead to orchitis, or inflammation of the testicles. While this complication is rare, if it does occur, it can impair sperm production and sometimes lead to permanent sterility.

Getting Treatment

Unfortunately, many times infections do not cause any symptoms. STDs in particular are known for not producing any signs or symptoms.

As a result, getting treatment for the infection may be delayed or never occur causing permanent damage to the reproductive organs. If your sperm production or reproductive tracts have been extensively damaged, it may be necessary to use surgical sperm retrieval methods in combination with ICSI and IVF. Alternately, you may decide to use a sperm donor in combination with IUI.

In cases where symptoms do emerge or the infection is caught early on, antibiotics may be prescribed which should clear up the problem, thereby minimizing any damage to your fertility. If damage, such as scarring or blockage, has already occurred in your reproductive tract, then surgery may be done that can clear up the block or remove the scar tissue.

Treatment

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The Prostate

The prostate is basically a male sex gland, about the size of a walnut, located beneath the bladder. (Read about “The Urinary System”) It makes some of the fluid that carries sperm. The gland is made of two lobes, or regions, enclosed by an outer layer of tissue. The prostate also surrounds the urethra, the canal through which urine passes out of the body.

Prostate problems are not unusual for men over age 50. As men age, the likelihood of problems increases. In fact, according to the National Institute on Aging, as many as 90 percent of American men in their 70’s and 80’s experience prostate problems.

The American Foundation for Urologic Disease says there are three main types of prostate problems – prostatitis or infections and inflammation, enlargement (also known as benign prostatic hypertrophy or benign prostatic hyperplasia), and cancer. Prostatic Intraepithelial Neoplasia (PIN) is another concern. Below find information on these four prostate concerns.

Prostatitis and Infertility

Prostatitis is one of potential cause of male infertility. It is an infection in the prostate gland and its symptoms range from none to urgency, painful urination, and pain during or after ejaculation, with or without pain in the prostate. It can usually be diagnosed though a physical examination and lab tests, and may be require treatment with antibiotics. Please warn him about this if you plan kids.

Definition

Prostatitis is inflammation or infection of the prostate gland ï¿½ an organ about the size and shape of a walnut, located just below the bladder in males. The prostate gland produces semen, the fluid that helps nourish and transport sperm. Prostatitis can cause a variety of symptoms, including a frequent and urgent need to urinate and pain or burning when urinating often accompanied by pelvic, groin or low back pain.

Prostatitis has been classified by the National Institutes of Health (NIH) into four categories.

Category 1 is acute bacterial prostatitis.

Category 2 is chronic bacterial prostatitis.

Category 3 includes the conditions previously known as nonbacterial prostatitis, prostatodynia and chronic pelvic pain syndrome.

Category 4 is asymptomatic inflammatory prostatitis.

Pain relievers and several weeks of treatment with antibiotic are typically needed for category 1 and 2 prostatitis, which are bacterial infections. A variety of treatments as well as self-care measures also can provide relief. Treatment for category 3 prostatitis (nonbacterial) is less clear and mainly involves relieving symptoms. Category 4 prostatitis is usually found during examination for another reason and often doesn’t require treatment.

Symptoms

The signs and symptoms vary depending on the various types of prostatitis.

Acute Bacterial Prostatitis: Category 1

Fever and chills

Flu-like symptoms

Pain in the prostate gland, lower back or groin

Urinary problems, including increased urinary urgency and frequency, difficulty or pain when urinating, inability to completely empty the bladder, and blood-tinged urine

Painful ejaculation

Acute prostatitis can be a serious condition and requires immediate medical treatment. See your doctor right away if you develop any of these signs and symptoms.

Chronic Bacterial Prostatitis: Category 2

The signs and symptoms of this type of prostatitis develop more slowly and usually aren’t as severe as those of acute prostatitis.

In addition, times when symptoms are better tend to alternate with times when symptoms are worse. Signs and symptoms of chronic bacterial prostatitis include:

A frequent and urgent need to urinate

Pain or a burning sensation when urinating (dysuria)

Pain in the pelvic area

Excessive urination during the night (nocturia)

Pain in the lower back and genital area

Difficulty starting to urinate, or diminished urine flow

Occasional blood in semen or in urine (hematuria)

Painful ejaculation

A slight fever

Recurring bladder infections

Chronic Nonbacterial Prostatitis: Category 3

The signs and symptoms of nonbacterial prostatitis are similar to those of chronic bacterial prostatitis, although you probably won’t have a fever.

The only way to determine whether prostatitis symptoms are caused by bacterial infection or are nonbacterial is through lab tests to find out whether bacteria is present in the urine or prostate gland fluid.

Other Conditions

Prostatitis can be difficult to diagnose, in part because its signs and symptoms often resemble those of other conditions, such as bladder infections, bladder cancer or prostate

Causes

Acute Bacterial Prostatitis: Category 1

Bacteria normally found in your large intestine typically cause acute prostatitis. Most commonly, acute prostatitis originates in the prostate, but occasionally the infection can spread from a bladder or urethral infection.

Chronic Bacterial Prostatitis: Category 2

It’s not entirely clear what causes a chronic bacterial infection. Sometimes it develops after an episode of acute prostatitis when bacteria remain in the prostate. Catheter tubes used to drain the urinary bladder, injury to the urinary system (such as from bike riding or horseback riding ) or infections in other parts of the body can be the source of the bacteria.

Chronic nonbacterial prostatitis: Category 3

The cause or causes of this condition are not well-defined. Some theories regarding the causes are as follows:

Other infectious agents. Some experts believe nonbacterial prostatitis may be caused by an infectious agent or agents that do not show up in standard laboratory tests.

Heavy lifting. Lifting heavy objects when your bladder is full may cause urine to back up into your prostate causing inflammation.

Interstitial cystitis. This condition that’s more frequently diagnosed as a cause of chronic pelvic pain in women is being more frequently recognized in men.

Physical activity. Although regular exercise, especially jogging or biking, is great for the rest of your body, it may irritate your prostate gland.

Pelvic muscle spasm. Urinating in an uncoordinated fashion with the sphincter muscle not relaxed may lead to high pressure in the prostate and the development of inflammation and prostatitis symptoms.

Structural abnormalities of the urinary tract. Narrowings (strictures) of your urethra may cause increased pressure during urination and result in inflammation and symptoms.

Prostatitis is not contagious and is not a sexually transmitted disease argement due to benign or cancerous growth of the prostate.

Risk Factors

Unlike other prostate problems, you’re more likely to develop prostatitis when you’re younger, even before age 40.

You may also be at increased risk if you:

Recently had a bladder infection or an infection of your urethra

Recently had a urinary catheter inserted during a medical procedure

Do not empty your bladder frequently enough and you perform vigorous activities with a full bladder

Jog or bicycle on a regular basis or ride horses

Men with HIV also are at increased risk of bacterial prostatitis. It’s not clear why.

Tests and Diagnosis

Diagnosing prostatitis involves ruling out any other conditions that may be causing your signs and symptoms and then determining what kind of prostatitis you have.

Your doctor will likely begin by taking a medical history and performing a physical exam. You may be asked to complete a questionnaire about your symptoms. The physical exam may include checking your abdomen and pelvic area for tenderness and a digital rectal exam of your prostate.

Because the prostate gland is in front of the rectum, your doctor can feel the back surface of the gland this way. If it seems enlarged and tender to the touch, you may have prostatitis.

Urine And Semen Test

Your doctor may want to evaluate samples of your urine and semen for bacteria and white blood cells ï¿½ key cells in your immune system’s response ï¿½ to help establish a diagnosis of prostatitis.

Complications

There’s no evidence that having acute or chronic prostatitis increases your risk of prostate cancer, but it may increase the level of prostate-specific antigen (PSA) in your bloodstream. PSA is a substance naturally produced in your prostate gland, and high levels in your blood may sometimes ï¿½ but not always ï¿½ be a sign of prostate cancer. For that reason, if you have an elevated PSA level and also have acute prostatitis, you should be rechecked after you’ve been treated with antibiotics and all prostate inflammation has resolved.

Because prostatitis interferes with the transport of sperm cells and may interfere with normal ejaculation, it can sometimes affect fertility. In addition, untreated acute prostatitis can lead to an inability to urinate, and in severe cases may result in bacteria in your bloodstream (bacteremia).

Lifestyle and Home Remedies

Because traditional treatments aren’t always effective for prostatitis, many men experiment with various lifestyle changes to control their symptoms. Although no scientific evidence proves these practices are beneficial, you may want to try one or more of the following suggestions:

Drink plenty of water.

Limit or avoid alcohol, caffeine and spicy foods.

Urinate at regular intervals.

Have regular sexual activity.

If you’re a cyclist, use a “split” bicycle seat, which reduces the pressure on your prostate.

Men with category 3 prostatitis can learn to live with the disease by limiting the things that make their symptoms worse and emphasizing the things that make them feel better.

Prostate Enlargement (Hypertrophy/Hyperplasia)

Benign prostatic hypertrophy or BPH is an enlargement of the prostate. The National Institute on Aging (NIA) says that more then half of men in their 60’s have BPH. An enlarged prostate can block the urethra. That can make it hard to urinate and create other issues. (Read about “The Urinary System”)

If you have BPH, the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) says you may have one or more of these problems:

a frequent and urgent need to urinate, even getting up several times a night to go to the bathroom

trouble starting a urine stream, even when you feel you have to rush to get to the bathroom

a weak stream of urine

a small amount of urine each time you go

the feeling that you still have to go, even when you have just finished urinating

leaking or dribbling

small amounts of blood in your urine

You may barely notice that you have one or two of these symptoms, or you may feel as though urination problems have taken over your life.

BPH is diagnosed usually with a digital rectal exam. The doctor inserts a gloved finger into the rectum and feels the part of the prostate that sits next to it. This exam gives the doctor a general idea of the size and condition of the prostate. X-rays or ultrasound may be used as well. (Read about “X-rays” “Ultrasound Imaging”) Another way to see a problem from the inside is with a cystoscope, which is a thin tube with lenses like a microscope. (Read about “Endoscopy”) The tube is inserted into the bladder through the urethra while the doctor looks through the cystoscope.

Once confirmed, patients have a number of treatment options, in consultation with their doctors. According to the National Institutes of Health, these include:

Watchful waiting – This is where no treatment occurs, but regular exams follow the progress of the disease. This path is often chosen by men who aren’t bothered by the symptoms.

Drugs – There are a number of new drugs that are being used to treat BPH. Some act on muscles near the prostate, to relax them. Side effects can include headaches and dizziness. Other drugs act directly on the prostate by impacting the effect of hormones, causing the prostate to shrink. Side effects can include sexual dysfunction issues. NIDDK says the long-term effect of all these drugs is unknown since they are so new.

Surgical techniques are the third option for BPH. Some are what is called minimally invasive, others are more involved and can result in potential complications. Some of the less invasive techniques include:

Prostatic stents are placed in the urethra to hold it open. They do have complications and aren’t usually considered a good long-term solution.

Microwave therapy uses the heat generated by microwave energy to destroy enlarged portions of the prostate surrounding the urethra. It is also called transurethral microwave therapy (TUMT).

Transurethral needle ablation (TUNA) uses radio waves to destroy enlarged tissue surrounding the urethra. It is also called radiofrequency therapy.

Interstitial laser therapy (ILT) is a little more invasive. A small laser is actually inserted into the prostate via the urethra. The laser heats and destroys prostate tissue.

Each of these methods involves inserting tools via the tip of the penis into the urethra. Some other surgical techniques also use this method to reach the prostate. They include:

Transurethral incision of the prostate (TUIP) involves just cutting the prostate to relieve the pressure. Prostate tissue is not removed.

Laser surgery can also be used to remove prostate tissue by vaporizing it.

The most invasive form of prostate surgery is called open prostatectomy. With this, the surgeon makes a cut in your lower abdomen to reach the prostate and remove tissue.

Prostatic Intraepithelial Neoplasia (PIN)

There is another condition called prostatic intraepithelial neoplasia or PIN. The National Cancer Institute (NCI) calls it a noncancerous growth of the cells lining the internal and external surfaces of the prostate gland. The American Cancer Society says PIN can be labeled either low or high grade. It is usually discovered after a biopsy. (Read about “Biopsy”) Having high-grade PIN may increase the risk of developing prostate cancer. ACS says there is a 30 to 50 percent chance of finding prostate cancer with later biopsies after finding high grade PIN.

Prostate Cancer

The National Cancer Institute (NCI) reports that prostate cancer is the second most common cancer among men in the United States and the number two cancer killer. (Skin cancer is more common and lung cancer is deadlier; read about “Skin Cancer” “Lung Cancer”)

Age is the biggest risk when it comes to prostate cancer. The older a man gets, the more likely he might develop it. Black males have a higher risk in all age groups. The U.S. Centers for Disease Control and Prevention say that prostate cancer among African Americans is the highest known rate in the world. Family history (Read about “Family Health History”) also seems to play a part, with a higher then average risk for those whose father, brother or son has had the disease, according to NCI.

Prostate cancer often does not cause symptoms for many years. By the time symptoms occur, the disease may have spread beyond the prostate. When symptoms do occur, NCI says they can affect your urinary system (Read about “The Urinary System”) and other areas, and may include:

frequent urination, especially at night

inability to urinate

trouble starting or holding back urination

a weak or interrupted flow of urine

painful or burning urination

blood in the urine or semen

painful ejaculation

frequent pain in the lower back, hips, or upper thighs

These can be symptoms of cancer, but more often they are symptoms of noncancerous conditions. It is important to check with a doctor.

Finding the cancer isn’t always easy. There is much discussion at this time about screening methods and when they should start. You should discuss with your doctor what would be the best path for you as you age. NCI says diagnosing cancer is done in a variety of ways:

A digital rectal exam can discover hard areas or lumps that could be cancer. The doctor inserts a gloved finger into the rectum and feels the part of the prostate that sits next to it. This exam gives the doctor a general idea of the size and condition of the prostate.

A PSA or prostate specific antigen blood test can show elevated levels of this substance if the patient has cancer or BPH. PSA isn’t always accurate. That means it can give elevated levels when there isn’t a problem, or it may not show high levels even though there is.

A biopsy will take a small portion of the prostate with a needle and examine it under a microscope to look for cancer cells. (Read about “Biopsy”)

The American Cancer Society recommends regular screenings for prostate cancer for men beginning at age 50, or earlier if there are risk factors present, including African-American men and men with a family history of prostate cancer. Remember, cancer of the prostate can have no noticeable symptoms in its early stages – and when it’s in its early stages, the cancer can more readily be cured. So talk with your doctor about the screenings you need now and in the coming years.

Treatment

Treatment for Prostatitis by Dr. & Hakeem Tariq Mehmood Taseer

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Blood in Semen

What is blood in the semen?

The presence of blood in the semen (ejaculate) is also called hematospermia. Hematospermia is an uncommon condition.

What are the causes of blood in the semen?

Rumke and Wilson first reported the presence of antisperm antibodies in infertile men in 1954. The incidence of sperm autoimmunity in infertile couples is 9-36% in contrast to 0.9-4% in the fertile population. The incidence of detection of sperm antibodies in the fertile male is 8-21% and in the female 6-23%. Immunological cause may contribute to 5-15% of the male infertility factors.

Blood in semen can be caused by many conditions affecting the male genitourinary system. Areas affected include the bladder, urethra, the testicles, the tubes that distribute semen from the testicles (known as the seminal vesicles), the epididymis (a segment of the spermatic ducts that serves to store, mature and transport sperm), and the prostate gland.

Blood in the semen is most commonly a result of a prostate-gland biopsy. More than 80% of men who undergo a prostate biopsy may have some blood in their semen that persists for three to four weeks. Likewise, vasectomy can lead to bloody semen for about one week after the procedure.

In men with hematospermia who have not had a recent prostate biopsy or vasectomy, a number of benign and malignant conditions of the male genital system may be the cause. In many situations, no definitive cause is found.

The following conditions have been reported in association with hematospermia:

benign or malignant tumors of the prostate, bladder, testes, or seminal vesicles,

inflammation of the prostate (prostatitis), epididymis (epididymitis), or urethra (urethritis),

calculi (stones similar to kidney stones) in the seminal vesicles or prostate,

polyps in the urethra,

ejaculation-duct obstructions,

metastatic cancers (that have spread from other sites in the body) located in the genitourinary system, and

cysts, hemorrhage, or other abnormalities in the seminal vesicles.

What are the symptoms of blood in the semen?

The symptoms that accompany blood in the semen may be any of the following, depending upon the cause (these are not all inclusive):

painful urination

pain with ejaculation

blood in urine

lower back pain

fever

tenderness in the testes and/or scrotum

swelling in the testes and/or scrotum, or

swelling or tenderness in the groin area.

How is blood in the semen evaluated?

A number of diagnostic tests may be performed after the clinical history is evaluated and a physical examination is performed. Some of the most commonly performed diagnostic tests are a urinalysis and cultures to identify any sexually transmitted or other infections. When indicated, imaging studies such as ultrasound or MRI may reveal tumors or other abnormalities. In some cases, a semen analysis may be recommended.

What is the prognosis (outlook) for patients with blood in the semen?

The prognosis relates to the underlying cause of blood in the semen if a cause can be identified. However, most cases of hematospermia are benign and resolve without treatment. While cancer is a rare cause of blood in the semen, the majority of cases are not related to cancer, especially in younger men.

Blood in Semen At A Glance

Blood in the semen is known as hematospermia

Prostate biopsy is the most common cause of blood in the semen

Blood in the semen can be caused by tumors, infections, anatomical abnormalities

stones, or inflammation in many sites throughout the genitourinary system

Usually blood in the semen is benign and resolves on its own

Treatment, if indicated, depends upon the underlying cause

White Blood Cells and Semen

If you and your partner are having trouble getting pregnant, then you may already be undergoing fertility testing or treatment. Male infertility accounts for up to 50% of all fertility issues, so it is a wise idea to have yourself tested. A semen analysis often brings to light fertility issues. In particular, many men discover that they have an elevated number of white blood cells in their semen. These white blood cells can negatively affect your fertility and may indicate an underlying health problem.

What Are White Blood Cells?

White blood cells are an essential part of the body’s immune system. They help us to fight off invading cells and bacteria, keeping our bodies healthy and infection-free. Also known as leukocytes, white blood cells are produced in our bone marrow. They move throughout our bloodstream, attacking any foreign bacteria, fungi, or viruses. During an infection, an increased number of white blood cells can be found in certain areas of your body.

White Blood Cells in the Semen

White blood cells are found in pretty much any area of the body at any given time. They are typically found in small quantities in your semen and ejaculate. At low levels, white blood cells cannot affect your semen quality, and will thus have no impact on your fertility. However, high levels of white blood cells in your semen can cause serious fertility problems. Known as leukocytospermia, a high white blood cell count in semen is typically over one million leukocytes per milliliter.

How Common is Leukocytospermia?

Leukocytospermia is actually not that uncommon. It affects anywhere between 5% and 10% of the population, and may affect as many as 20% of those men currently seeking fertility treatment.

Men who have undergone vasovasostomy tend to have more leukocytes in their semen than normal.

What Causes Leukocytospermia?

Leukocytospermia is typically the result of a genital tract infection. The presence of high levels of white blood cells is needed to help fight off the infection. STDs are commonly associated with leukocytospermia, particularly chlamydia and gonorrhea. Other genital tract infections may also cause an increase in white blood cells.

How Do White Blood Cells Affect Fertility?

In large quantities, white blood cells can have a detrimental effect on male fertility. This is because leukocytes cause the oxidation of cells. If you have high numbers of white blood cells in your sperm, this could result in the oxidation of sperm cells, damaging their ability to fertilize an egg.

Reactive Oxygen Species (ROS)

Leukocytes trigger oxidation by releasing reactive oxygen species. These molecules cause cellular damage by changing the makeup of individual cells. In particular, reactive oxygen species change the makeup of sperm cells, affecting motility and morphology. This can make it very difficult for you and your partner to achieve pregnancy.

The more white blood cells you have in your semen, the more likely it is that you sperm have been affected by the reactive oxygen species. However, every man has a different threshold regarding the amount of reactive oxygen species his sperm cells can hold. This is because the body has specific antioxidants that fight against the damage caused by the reactive oxygen species. Some men simply have lower levels of these antioxidants, leaving them more susceptible to oxidative damage.

Testing and Treatment of High White Blood Cell Levels

If you are dealing with male factor infertility, your reproductive endocrinologist will be sure to test and treat you for high white blood cell levels.

Testing for High White Blood Cells Levels

Testing is typically performed at your fertility clinic. A semen analysis can detect the levels of white blood cells in your ejaculate. You will also be given a urethral swab to determine if you are suffering from an active infection.

Treating High White Blood Cells in Semen

Treatment typically involves medicating any active infections with the use of antibiotics. You may also be advised to ejaculate frequently, in order to move excess white blood cells out of the seminal tract. White blood cells levels tend to drop on their own, however, they can increase again at a later date, so active treatment is suggested.

Treatment

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Male Infertility and Obesity

Recent studies have found a link between male fertility problems and obesity. In fact, being overweight or obese is one of the central causes of male infertility and more specifically, of sperm health problems. But how exactly does a man’s weight affect his fertility and what types of male fertility problems does being obese cause?

A study found that men with a higher body mass index (BMI) had a significantly higher risk of being infertile compared with men considered to be normal weight. In fact, the study found that an increase of just 20 lbs. could increase the chance of male infertility by approximately 10%.

BMI is a tool that measures weight proportionate to height and helps to calculate an individual’s body fat. Individuals with a lot of muscle sometimes have higher BMIs due to the fact that muscle tissue weighs more than fat tissue.

A BMI of 18.5 to 24.9 is considered to be normal for adults while a BMI of more than 25 is considered to be overweight. Obesity is defined as having a body mass index of more than 30 while morbid obesity is characterized by a BMI of 40 or higher.

A separate study found that a link between obesity and sperm health. The study compared male BMI to DNA fragmentation in sperm. As BMI, so too did the fragmentation of sperm DNA in the participants. Deteriorated sperm quality increased significantly as BMI passed 25 and was acute in participants whose BMI was over 30. Fragmented sperm DNA is linked to reduced fertility as well as an increased risk of miscarriage.

In addition, obesity can have a number of other effects on male fertility:

low sperm count and concentration

hormonal imbalance

increased scrotal temperature

decreased libido

As such, it is important to maintain good overall health in order to reduce the risk of male fertility problems and in order to maintain good reproductive health. Following a healthy diet and exercising regularly are important steps in reducing weight can help to achieve a healthy weight as well as improve sperm health. Talk to your doctor about starting a healthy exercise regimen and for advice on healthy eating in order to make important lifestyle changes that can help to increase your fertility.

Sperm Health

Sperm health is vital to increasing a couple’s chances of getting pregnant. While certain genetic conditions might affect a man’s sperm health, there are a variety of factors, ranging from environmental to lifestyle, that also influence male fertility.

As such, men can follow simple sperm health tips in order to increase fertility so as to improve their partner’s chances of getting pregnant.

Sperm Health Tips that Can Help Improve Male Fertility

The following tips can help to alleviate male fertility problems so as to improve a couple’s chances of getting pregnant:

don’t smoke. Smoking is linked to sperm health problems. While smoking has not been linked to a lowered sperm count, it does cause damage to sperm DNA, which results in an increased risk of birth defects in a man’s children. Because it takes three months for sperm to fully form, it is imperative to quit smoking at least three months prior to trying to get pregnant in order to reduce the risk of birth abnormalities

don’t do drugs. Drug use also negatively influences sperm health. For example, marijuana increases the number of abnormal sperm produced, as well as lowers overall sperm count.

limit your alcohol intake. Reducing your alcohol consumption to no more than two drinks a day is also important to male fertility. In fact, excessive drinking can lead to impotence.

maintain a healthy weight. Because being either overweight or underweight can influence sperm health, maintaining a healthy weight is crucial in order to increase male fertility. A BMI of less than 20 or of more than 25 can reduce a man’s sperm count by 22%. Your BMI can be calculated by dividing your weight in kilograms by your height in meters squared. Following a healthy diet that is low in saturated and trans fats and that is high in folic acid, zinc, vitamins A, C and E is essential to staying healthy. Exercise can also help to maintain good weight.

get sun exposure. A healthy amount of sun exposure is linked to increased levels of testosterone, which in turn is connected to healthy sperm production. In addition, sun exposure is linked to lower levels of melatonin, which are known to negatively impact male fertility.

don’t overdo it. Studies have shown that ejaculating more than twice a day can have a negative effect on male fertility. This is because it takes some time for sperm levels to rise again following ejaculation. Nonetheless, it is important to have intercourse with your partner on a regular basis because sperm that is not ejaculated becomes old and less fertile, thereby reducing the chances of getting pregnant.

avoid heat. Overheating of the testicles can reduce sperm health. It is important for men to avoid wearing tightly fitting pants and undergarments, as well as to avoid hot baths and hot tubs. Also, placing a laptop on a table or desk as opposed to directly on the body also reduces the risk of sperm health damage.

reduce stress. Stress is a major contributing factor to sperm health problems. In fact, 15% of men experience decreased libido because of stress, while 5% of men experience impotence because of it. Practicing relaxation methods such as Pilates can help to minimize stress, as does participating in regular exercise.

Obese Couples Risk Lower Fertility

Study Shows Weight of Both Partners May Affect Conception

March 7, 2007 — A couple trying to conceive may face an extra challenge when both the man and the woman are overweight or obese, new research suggests.

Compared with normal-weight couples, obese couples participating in a Danish study were almost three times as likely to take more than a year to achieve a pregnancy.

Previous studies have shown that weight can affect fertility in women, but the Danish study is the first to examine the impact of overweight or obesity in couples.

The findings strongly suggest, but do not prove, a causal association between excess weight in both partners and decreased fertility

“Because of the study design we cannot say for a fact that it is extra body fat that makes people less fertile, but it certainly appears that this is the case,” she says. “If a couple is overweight and wants to have a child it may be beneficial for both partners to attempt weight loss.”

Weight Loss Reduced Time to Conception

The researchers analyzed data from 47,835 couples who participated in a nationwide study of pregnancy outcomes in Denmark. Women in the study completed four interviews over a period of two years, giving information for both themselves and their partners on weight, height, previous pregnancies, smoking, and socioeconomic status.

The findings are published in the March issue of the journal Human Reproduction.

A total of 8.2% of the women, 6.8% of the men, and 1.4% of the couples in the study were obese, defined as having a body mass index (BMI) of 30 or more. BMI looks at weight in relation to height and is used as an indicator of body fat.

As measured by BMI, a 5-foot-2-inch person who weighs 165 pounds or more is considered obese, as is a 6-foot-tall person who weighs 220 or more.

Just over half of the men and two-thirds of the women in the study were normal weight.

Ramlau-Hansen and colleagues from Denmark’s University of Aarhus evaluated the time it took the couples to become pregnant. Sub-fertility was defined as failure to conceive for at least a year after initiating unprotected sex with the goal of conceiving.

Obese women had a 78% greater risk of being sub-fertile than normal-weight women, and obese men had a 49% increased risk for sub-fertility than normal-weight men.

The risk of taking more than a year to achieve a pregnancy was 2.74 times higher when both partners were obese than for a normal-weight couple.

The researchers further examined 2,374 couples who had more than one pregnancy. When they converted the length of time that it took the women to get pregnant into days, they concluded that for overweight or obese women, every 2.2 pounds of weight loss reduced the time to conception by an average of 5.5 days.

Heavier Men Have Less Sex

The suggestion that weight loss seems to improve fertility for both women and, to a lesser extent, men has important potential public health implications, says epidemiologist Donna Baird, PhD, of the National Institute of Environmental Health Sciences (NIEHS).

Baird co-authored a 2006 NIEHS study that linked obesity to infertility in men. The researchers concluded that a 3-unit increase in BMI increased the risk of infertility by about 10%.

At least one other study has linked obesity in men to a decline in sperm quality, but Baird says more research is needed to confirm the association between body weight and infertility in men.

She adds that the decline in fertility among overweight and obese men may have more to do with sexual function than sperm quality.

“There are a lot of gaps in what we know,” she tells. “We didn’t have data on the frequency of sexual intercourse among men, and we know that obesity can certainly impact sexual function. Low libido and erectile dysfunction, for example, are much more common in obese men.”

Infertilityis a medical condition characterized by a diminished or absent ability to produce offspring. It does not imply (either in the male or the female) the existence of as serious or irreversible a condition as sterility. Although infertility is a common condition, it is often hard to pin down its source. Men and women may each have risk factors that can contribute to infertility, and those risk factors can be genetic, environmental or related to lifestyle. One of the most common and well documented risk factors for infertility in both men and women is obesity.

Obese Women and Infertility

Numerous studies report that women who are overweight or obese tend to have a more difficult time becoming pregnant than normal-weight women. Moreover, once pregnancy occurs, obese women have a higher rate of pregnancy loss.

Being overweight can also lead to abnormal hormone issues affecting reproductive processes for both women and men. Abnormal hormone signals, as a result of excess weight, negatively impact ovulation and sperm production. In women, it can cause the overproduction of insulin, which may cause irregular ovulation. There is also a link between obesity, excess insulin production and the infertility condition known as polycystic ovarian syndrome (PCOS). PCOS is a specific medical condition associated with irregular menstrual cycles, anovulation (decreased or stopped ovulation), obesity and elevated levels of male hormones.

Obese Men and Infertility

Obesity does not solely affect women’s fertility though. Most recently, studies conducted at the U.S. National Institute of Environmental Health Sciences (NIEHS) are confirming that men with increased body mass indexes (BMI) are significantly more likely to be infertile than normal-weight men. The NIEHS data suggests that a 20-pound increase in a man’s weight may increase the chance of infertility by about 10 percent.

Hormone irregularities in men affect stimulation of the testicles that inhibit sperm production. Excess fat actually causes the male hormone, testosterone, to be converted into estrogen, and those estrogens decrease testicle stimulation. Researchers from Reproductive Biology Associates report that a high BMI in men correlates with reduced testosterone levels. The study showed overweight men to have testosterone levels 24 percent lower than men of normal weight, and obese men to have levels 26 percent lower. Men with high BMIs typically are found to have an abnormal semen analysis as well.

Hormones

Excess body fat also impacts production of the gonadotropin releasing hormone (GnRH), which is essential to regular ovulation in women, and to the production of sperm in men. Specifically, GnRH triggers release of the luteinizing hormone (LH) and follicle-stimulating hormone (FSH), both critical to the development of eggs and sperm.

In Vitro Fertilization

When one or both of the partners suffer from infertility, whether or not related to obesity or hormonal imbalances, often they turn to in vitro fertilization (artificially assisted) for help in conceiving. A recent research study comparing the success rates of 5,800 in vitro fertilization attempts with the BMI of the female participants found that obese women with a BMI more than 35 had lower success rates compared with overweight (BMI of 25-30) or normal weight women (BMI of 20-25).

Additionally, obese women were found to have a lower rate of success with embryo implantation (13 percent vs. 19 percent among healthy weight women). They were also less likely to become pregnant after in vitrofertilization (22 percent became pregnant vs. more than 30 percent of normal weight women). Researchers suggest that doctors should encourage their patients to reach a healthy weight before attempting in vitro fertilization.

Keeping the Weight Off

Even when mild, obesity substantially increases poor pregnancy outcomes. Many patients seek to follow the advice of their physicians and lose weight before becoming pregnant. When one is 100 or more pounds overweight, however, the time frames involved in taking off such a significant amount of weight, and the fear of it returning with pregnancy are daunting at best. Many infertile individuals, especially women, turn to weight-loss surgery options to help them reduce their weight, and give them a tool to use along with newly learned skills to keep the weight off.

Weight-loss Surgery and Pregnancy

Women seeking surgical intervention for their obesity issues are advised not to become pregnant for at least 18 months following surgery. However, some women do become pregnant while still in the active weight-loss phase post-surgery.

After any weight-loss surgery that restricts food intake and/or has a malabsorptive component, some basic precautions should be taken before becoming pregnant. Severe iron deficiency anemia and vitamin B12 deficiency resulting from malabsorption can complicate pregnancy following gastric bypass surgery for morbid obesity. In general, vitamin B12 deficiency responds to parenteral treatment (IV or injection), and mild to moderate iron deficiency best responds to oral iron supplementation caused by the malabsorption component of the bypass.

Additionally, pregnant women should be aware of the levels of vitamin A in their post-surgical vitamin regimen. Women having had gastric bypass with a malabsorptive component should ask their doctors for a prescription for a non-acid dependent prenatal vitamin to ensure maximum absorbability.

While pregnancy is not recommended during the period of rapid weight-loss in the initial post-operative period, it can be managed effectively with the assistance of both the bariatric surgeon and OB/GYN who specializes in high risk pregnancies. Data indicates that a pregnancy which develops after the period of rapid postoperative weight-loss also shows that neither the mother nor the developing fetus is unduly endangered if appropriate precautions, monitoring and nutritional care are provided.

Conclusion

Obesity is a major health issue associated with infertility and many other co-morbid conditions. Studies show weight-loss is extremely valuable in the management of such patients, can enhance fertility, and lead to successful full term pregnancies.

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Immunology of Male Infertility

Rumke and Wilson first reported the presence of antisperm antibodies in infertile men in 1954. The incidence of sperm autoimmunity in infertile couples is 9-36% in contrast to 0.9-4% in the fertile population. The incidence of detection of sperm antibodies in the fertile male is 8-21% and in the female 6-23%. Immunological cause may contribute to 5-15% of the male infertility factors.

ASA can be defined as immunoglobulines of the IgG, IgA and/or IgM isotype that is directed to various aspects of the spermatozoa (head, tail, midpiece or combination thereof). Immunoglobulin M is too large molecule to cross into the semen. Immunologic infertility is probable if more than 50% sperm are bound to IgG or IgA antibodies. It may be suspected if more than 10% spermatozoa are antibody bound. These immunoglobulines can be found in both males and females and in serum, semen and cervical mucus.

The blood-testis barrier, the tight junctions between Sertoli cells appears to play a major role in keeping the developing spermatozoa and immune system separate. It prevents those testicular cells expressing “foreign” antigens from coming into contact with lymphoid tissue and immunocompetent cells from entering the seminiferous tubules. However, the BTB is commonly breached by physiological leakage of normally sequestered sperm antigens. Since tight junction does not protect all intratesticular sperm autoantigen due to the presence of autoantigenic cells (spermatogonia and early spermatocytes) below the junction in the basal compartment, other immunosuppressive mechanisms are necessary.

2.Binding of antibodies to posttesticular spermatozoa and inhibiting their effective transport in male reproductive tract

3.Autoagglutination of ejaculated spermatozoa.

4.Sperm cytotoxicity mediated by sperm antibodies.

5.Direct immobilizing effect of sperm antibodies on spermatozoa in the female tract. Enhancement of phagocytic clearance of spermatozoa by macrophages.

6.Inadequate spermatozoal traverse of cervical mucus.

7.Disorders of sperm capacitation and acrosome reaction

8.Blockage of sperm-ovum interaction

9.Induction of sperm immunity in the female

10.Postfertilization reproductive failure and occult abortion

Risk factors of development of male antisperm antibodies (ASA) have been reviewed by Heidreich et al. (1994)

Antisperm antibodies were found in 25-56% of men with chronic prostatitis.It is suggested that the presence of antisperm antibodies on the sperm of the male partner may induce an immune response in the female partner, although most studies of Intrauterine Insemination did not confirm increased incidence of ASA. Women with pelvic infection have a higher incidence of sperm immunity (up to 59%). Antibody production is linked to chlamydial, mycoplasmal and ureaplasmal infection.

Indications For Antisperm Antibody Testing

Patient Selection

Overall, in the male it is best to measure ASA directly on the sperm. Only semen carries inhibitory effect of a manís antibody to subsequent reproductive events. Therefore, it is important to discover whether antibodies are present on sperm, not in serum.

Azoospermia is the only exception when serum testing is necessary. IgG are the only immunoglobulins that transsudate and secretory IgA present on mucous membranes. IgM is a very large molecule that does not transsudate to the reproductive tract; therefore, such testing is unnecessary.

Treatment

Laboratory Techniques

Methods of preventing binding or separate antibody- free sperm in the laboratory indicate conflicting results. Splitting of the ejaculate was not effective in limiting the degree of binding. There are mixed report on simple sperm washing. Sperm antibody binding was also not reduced by Percoll gradient separation. The investigational techniques presently include

Protease treatment to destroy antibodies on the sperm surface

Immunoadsorption

Antigen-specific immunoadsorption

Assisted reproduction technologies:

IUI affords some increase in pregnancy rates over no treatment but this increase may be modest. Antibody induced deficit of the fertilization process will not be completely circumvented by IUI The reported average success rate for IUI in couples with male factor antisperm antibodies is 20%. Increased ovarian hyperstimulation may yield better results in such treatment plan but has not been well studied.

Pregnancies with GIFT have been achieved in couples who failed washed sperm IUI and steroid therapy. ICSI is the current accepted advanced ART treatment in men with high level of ASA. In one study where ASA binding approached 80%, the mean fertilization rate, embryo development and pregnancy rate were comparable to another cohort of ICSI cases without immunologic infertility. If these results will be confirmed by another studies, ICSI should be the primary choice for patients with high immunologic infertility.

Immunology Factors in Infertility

Anti-sperm antibodies can occur in both men and women. Antibodies are protein molecules that are attracted to a specific site on the sperm. Once attached, they may interfere with the sperm’s activity in any of several ways. They may immobilize sperm, cause them to clump together, limit their ability to pass through the cervical mucus, or prevent them from binding to and penetrating the egg. Anti-sperm antibodies are frequently seen in men after vasectomy, testicular injury or infection. The cause of anti-sperm antibodies in the woman is unknown.

Researchers classify specific antibodies by type (IgA, IgG and IgM) as well as the point at which they attach to the sperm (head, midpiece, or tail). Studies indicate that IgG type antibodies are most common in men and that IgA type can be found in women’s mucus and follicular fluid, but the significance of these findings is uncertain. Binding to the head is believed to interfere with attachment and penetration of the egg, while tail binding interferes with motility.

Unfortunately, testing and identification of type of antibody or the location does little to suggest who will or won’t conceive. Attempts to treat the condition — say, by lowering antibody levels with steroids or removing the antibodies from sperm — have demonstrated limited benefit and have been fraught with disastrous complications. A trial of ovulation induction and insemination followed by in vitro fertilization with ICSI (a process that involves injecting a sperm directly into an egg) seems to be the best treatment available.

Between 20 and 25 percent of all repeated miscarriages are due to immunological problems. In some cases, the woman’s immune system causes her body to reject the fetus as foreign tissue. This problem can often be solved by injecting white blood cells from the woman’s partner into her body before conception, so that her body gets “used to” his cells and therefore “recognizes” the fetus later on as “friendly.” Some clinics report about a 70 percent success rate using this method.

Other immunological causes involve women who produce antibodies that indirectly cause clotting in blood vessels leading to the developing fetus. The fetus is deprived of nutrients and dies in utero, which triggers an abortion. There are no definitive treatments, but some clinics are looking into combining acetylsalicylic acid (pain relievers), corticosteroids, or anticoagulants such as heparin.

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Ductal and Structural Abnormalities

Often times, a man may experience infertility due to structural problems in his reproductive organs. When organs or ducts have not developed properly or damage has occurred resulting in a blockage, it can cause a variety of fertility difficulties, ranging from lack of sperm in ejaculate to failure to produce sperm at all.

Often times, a man may experience infertility due to structural problems in his reproductive organs. When organs or ducts have not developed properly or damage has occurred resulting in a blockage, it can cause a variety of fertility difficulties, ranging from lack of sperm in ejaculate to failure to produce sperm at all.

Duct Blockage

There are many tubes and ducts that a manï¿½s sperm needs to travel through before it can leave the body. If there is a blockage in any of these tubes, it can result in male infertility, a condition known as obstructive azoospermia. The male reproductive ducts can become blocked for any number of reasons. Scar tissue that results after surgery to this area or an infection is a common reason as these adhesions act as barricades, preventing sperm from being able to join with a manï¿½s semen. Men who have had a vasectomy are also classified as having obstructive azoospermia.

If male infertility is caused by a blockage, there are a variety of surgeries that can be performed in order to reverse any damage. Men who have had a vasectomy will require a vasectomy reversal in order to regain their fertility. However, in situations where damage to the reproductive ducts is too extensive, surgical retrieval of the sperm may be necessary. Collected sperm can then be used in ICSI with IVF or IUI.

Congenital Defects

Congenital defects refer to structural problems in the reproductive system that a man may have been born with. Because part of their reproductive system has not formed or developed properly, difficulties with fertility can result.

CAVD

Men who are born without a vas deferens have a fairly rare condition known as congenital absence of the vas deferens (CAVD). Although the manï¿½s testicles function and produce sperm normally, because he lacks the vas deferens tubes, sperm is not able to join his semen.

While there is no way to replace a manï vas deferens, men diagnosed with CAVD can have their sperm surgically removed and used in ICSI-assisted IVF. However, because men with CAVD are more likely to be carriers of cystic fibrosis, you may want to consider using PGD during your IVF.

Hypospadias

Affecting between one in 150 and one in 350 male births, hypospadias is a common congenital defect. In men affected by hypospadias, the urethral opening (known as the meatus), which is normally found on the tip of the penis, is located on the underside of the penis. About 70% of those affected by hypospadias have their urethral opening located near the head of the penis but the opening can be located as far down as near the scrotum. A slight curvature to the penis is also associated with this condition as is an improperly formed foreskin. About 8% of those affected by this condition will also have an undescended testicle. While this defect is usually quite mild, in some cases the effects are more severe and can result in the penis curving downwards significantly, making sex virtually impossible.

Although milder instances of hypospadias are often left alone, as they do not interfere with sexual and reproductive functions, more serious cases can be treated through surgery. Depending on the extent of the damage one or several surgeries may be required to reposition the meatus and straighten out the penile shaft. Surgery can be done at a fairly young age, with many pediatric urologists preferring to perform the surgery between the ages of three and 18 months.

Undescended Testicles

During fetal development, the testicles begin to form in the abdomen before descending into the scrotum. In about three to four per cent of births, though, this descent fails to occur. In the majority of cases, this problem is naturally corrected within nine months of birth. However, boys who have at least one undescended testicle by age one will likely require surgery to correct the problem.

Not correcting this testicular problem can result in male infertility later in life. Regardless of whether the testicle descends into the scrotum or not, any man with undescended testicles at birth is thought to be at an increased risk of developing testicular cancer.

Other Congenital Defects

Not all congenital problems are treatable, thereby contributing to male infertility. One such defect is Kleinfelterï¿½s syndrome whereby a man has an additional ï¿½Xï¿½ chromosome. This extra chromosome results in abnormally small testes with poor function as well as azoospermia.

Man affected by Steroli-cell only syndrome, a very rare defect, will also have azoospermia. In men with Steroli-cell only syndrome, the necessary sperm producing cells are lacking thereby resulting in a poor reproductive function. While neither of these conditions can be effectively treated, men with either of these problems may still father a child by using TESE..

Structural Causes of Male Infertility

As with other causes of male infertility, physical structure of the male reproductive organs can have an impact on the ability to produce offspring.

Structural conditions which can contribute to male infertility fall into three main categories:

Testicular

Ductal

Penile

Testicular structural problems affecting male fertility include:

underdeveloped testes

missing testes or missing portions of the testes

deformity of the seminal vesicles – where the sperm is stored prior to ejaculation

Ductal problems can encompass:

Congenitally blocked vas deferens (the tube that transports sperm)

Malformed or absent seminal ducts – ducts through which sperm exits during ejaculation

Scarred ducts associated with infection

Genetically missing ducts

Penile structural problems may include:

Damaged musculature which prevents erection

Damaged urethra – the passage through which urine and sperm exit the body

Hypospadias – urinary opening on the underside of the penis rather than at the tip

Male infertility is a product of many different disorders, including structural problems within the male reproductive system. Only through thorough evaluation by an Infertility Specialist, can structural problems be identified and treated.

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Male Biological Clock

A man’s genes, coupled with the facts of his life, set the limits of his sexual biological clock. But men can still do a lot to improve their fertility and their sexual performance.

A man’s genes, coupled with his life circumstances, set the broad limits of his sexual biological clock. In other words, the quality of his semen and his sperm, his average testosterone level, and the quality of his erections are controlled, to a large extent, by his unique genetic heritage. But men can still do a lot to improve their fertility and their sexual performance. In this chapter, I’ll look at general ways that any man can slow or reverse his biological clock and improve his sexual health.

Following these guidelines will absolutely make a difference, regardless of your age or whether you have any current problems. Remember that sexual anatomy is a lot like a fairly complicated machine, and, like any machine, it will perform better if it is used properly and maintained regularly. Both men and their partners should consider what follows an instruction manual for the care and upkeep of the male sexual anatomy.

Eat the Proper Fuel, Do the Proper Amount of Exercise

The old cliche “You are what you eat” contains a fair amount of truth. A man’s body, including his sex organs, is made from the food he eats, the beverages he drinks, and the air he breathes. Eat right, and everything improves—including sexual health. As with most things in life, an appropriate guide for eating to promote sexual health is “All things in moderation, including excess.” The idea is to avoid extremes in any direction and yet preserve the pleasure of eating.

For example, much research shows that a high-fat diet, high cholesterol levels, and obesity lower testosterone levels and increase the risk of erection problems. That’s because excess fat is converted to estrogenlike compounds that curtail the production of testosterone, and fat in the blood can clog the small arteries that feed the penis. Remember, what is bad for the heart is bad for the penis. A recent study, in fact, found that, conversely, improving cardiac health improves erections, a fact recently illustrated by a study showing improved erectile function in a group of men treated with a cholesterol-lowering medication.

On the other hand, studies also show that very lean men—for example, marathon runners—have lower-than-average testosterone levels. That’s because the compound used to build testosterone molecules in the body is cholesterol, and extreme exercise lowers cholesterol levels to abnormal levels. A man needs enough cholesterol in his diet to maintain testosterone production, but not so much that it produces body fat or clogged arteries.

A similar dynamic exists with vitamins and minerals. Many studies in both animals and men show that deficiencies of vitamin E, vitamin B12, zinc, selenium, and a host of other vitamins reduce sperm production. But that doesn’t mean guys should go out and start popping extra zinc tablets. Taking megadoses of any vitamin can cause problems—the body is simply not built to absorb such large amounts, and a man will both be wasting money and harming his health by doing so.

Men need adequate levels of all the key vitamins, particularly the so-called antioxidant vitamins A, C, and E. Although the current recommended levels of these and other vitamins and minerals may not be perfect (they are revised periodically in light of new research), I think it makes sense to follow the latest recommendations and take a general-purpose vitamin supplement every day that will “cover your bases.”

Here are the latest dietary guidelines for men published by the National Research Council. This is the best guide for determining if you are eating enough of a given nutrient, such as fiber, and for determining how much, if any, vitamin and mineral supplements you need.

Vitamin C: 90 milligrams

Vitamin D: 10 micrograms

Vitamin E: 15 milligrams

Calcium: 1,200 milligrams

Iron: 10 milligrams

Zinc: 15 milligrams

Beta-carotene: 5–6 milligrams

Folate: 400 micrograms

Of course, it would be best if we all derived an optimal vitamin and mineral balance every day from the foods we eat, but that’s not always easy or possible these days. A supplement is particularly important for vegetarians or those on other limited diets because, unless one is very careful, vitamin and mineral deficiencies can occur.

Science has not found any particular diet that reliably improves testosterone or fertility. Everything points to the general idea that if a man eats for whole-body health, he’ll be eating for his sexual health as well. The following guidelines are recommended.

Avoid white flours, white rice, and sugar; all these cause large spikes in blood sugar levels that can sap energy and lead to adult-onset diabetes. Whole grains are far preferable (and are often more tasty as well).

Switch from saturated fats such as butter to unsaturated fats such as liquid oils.

Eat plenty of fruits and vegetables (just don’t drown them in butter or salad dressing)

Keep portions of protein, particularly red meat, modest.

Get more fiber in your diet. A morning high-fiber cereal is a very good way to help reach the recommended level.

Eat a diet that is balanced in protein, carbohydrates, and fats; you’ll feel less hungry. In general, consumption of carbohydrates increases appetite, while consumption of fats and proteins decreases appetite—but don’t push this to extremes.

These guidelines may sound overly simple, but you don’t need to follow complicated regimens, fancy diets, or other faddish ideas such as a low-carb diet, a low-protein diet, or a low-fat diet. Most people instinctively know how to eat well; the problem is not succumbing to the temptations produced by our inborn cravings for fat and sweets, cravings that served our species very well ten thousand years ago but are now causing us grief.

Optimal sexual health is also promoted by moderate, regular exercise. Again, the key is avoiding extremes. Studies show that men who exercise strenuously (i.e., men who run more than 100 miles a week or who bicycle more than 50 miles a week) usually have a lower testosterone level than men who exercise more moderately. Given that most men do not, in fact, exercise even moderately, this is not exactly a huge public health problem.

Exercise at any level, even walking, is better than no exercise, but maximum benefit is derived when exercise is strenuous enough to be aerobic, meaning any activity that uses large muscle groups, can be maintained continuously, and is rhythmic in nature. Such activity causes the heart and lungs to work harder than normal, which is the key to achieving both the physical and mental advantages of exercise.

When an overweight man, particularly one with excess abdominal fat, has a low testosterone level (which often is the case), I do not recommend that he begin exercising right away. It’s simply going to be frustrating because he will lack the drive and energy needed to exercise. Instead, I boost his testosterone levels medically, and almost always, he then finds he wants to exercise because it simply feels good. Exercise may cause an initial small weight gain from added muscle mass, but this is usually followed (in overweight men) by significant weight loss, because more calories will be burned and the added muscle mass raises a man’s metabolic rate.

Men need to think about their sexual health when they’re making choices about which foods to eat and whether or not to exercise. It’s one thing for a man to know in the abstract that it’s good to exercise and eat right; it’s quite another to understand that doing so will help his sex life and potency.

Quit Smoking

Several studies show that men who smoke have lower sperm counts and their sperm are somewhat more likely to be abnormally shaped. Smoking also makes it harder to get and maintain an erection because it releases (among other things) adrenaline and other stimulating compounds that make it harder for blood to flow into the penis in response to sexual stimulation. Smoking is one of the major risk factors for erectile dysfunction.

Clearly, however, smoking by itself doesn’t cause infertility, nor does it make sex impossible—if it did, the tobacco industry would be out of business very quickly! Smoking is just one of many lifestyle habits that when added together can significantly erode fertility or sexuality.

Avoid Anabolic Steroids

As we saw in Chapter 2, more and more men these days are using anabolic steroids to gain a competitive edge or become “bulked up.” Anabolic steroids act like testosterone in the body. Taking the doses commonly used by athletes is like flooding the body with extra testosterone, which cripples a man’s natural testosterone production and fertility. Although some athletes take steroids in six- to twelve-week cycles, resting in between in order to “give their bodies time to recover,” it actually takes between six months and a year for sperm and testosterone production to return to normal after a course of steroid use.

Anabolic steroids are simply bad for fertility—and ultimately bad for your overall health. (Note that corticosteroid medications such as prednisone and cortisone, which are used to relieve itching, rashes, allergic reactions, and other medical conditions, are not the same as anabolic steroids and have no effect on either fertility or sexuality.)

Avoid Hot Tubs

Hot tubs are great, and if all a man cares about is sex, there’s no harm done and possibly plenty of good to come from a nice relaxing soak (particularly if it’s done with a partner). Unfortunately, as mentioned earlier, heat and sperm are a bad mix. Sperm are made in the testicles, which usually hang from the body in the scrotum. As we’ve seen, the sperm-making cells of the testicles don’t work right unless they are cooler than body temperature by a few degrees Fahrenheit.

In order to keep the temperature of the testicles relatively constant, the scrotum is lined with temperature-sensitive muscles. In warm conditions the muscles relax and let the testicles hang far from the body, whereas cold temperatures (particularly cold water) make the scrotum contract, pulling the testicles tight against the body for added warmth. Soaking in a hot tub makes it impossible for the testicles to remain as cool as they would like to be, which may reduce sperm formation or harm sperm that are already made. (This impact on fertility also occurs if a man is running a high fever.)

Avoid Drugs

Abuse or long-term heavy use of alcohol, marijuana, cocaine, or practically any other recreational drug clearly impairs both fertility and sexual performance. As Shakespeare wryly noted in Macbeth, alcohol “provokes the desire, but it takes away the performance.” The same can be said for other drugs when used to excess.

But the jury is still out about whether occasional or moderate use of drugs has any kind of significant long-term effects on reproductive health. Although animal studies and research with relatively high doses of THC (the active ingredient in marijuana) have shown a negative effect on such factors as sperm quality and quantity, a recent report by the Institute of Medicine says: “It remains to be determined whether smoked marijuana or oral THC taken in prescribed doses has a clinically significant effect on the fertilizing capacity of human sperm.”2 In addition to this, the report notes that studies of marijuana’s effects on fertility “have yielded conflicting results.” The situation with alcohol is similar: effects can be demonstrated at high doses or in alcoholics, but the evidence is mixed at the levels most people consume.

Common sense suggests that men with fertility or erectile problems should abstain from, or indulge only very moderately in, alcohol or other recreational drugs.

Check Your Medications

Many medications commonly used to treat other illnesses or conditions can affect fertility or sexuality. As noted in previous chapters, some antidepressants impair erection and make it difficult or impossible to achieve an orgasm. (Of course, as we saw in Chapter 3, this can be an advantage for men with premature ejaculation.) Other medications degrade sperm quality. Here’s a list of the major classes of drugs that have the potential to harm sexual health:

Men who suspect that they are experiencing an adverse sexual reaction to a drug should talk to their doctor as soon as possible about switching to another drug or changing their dose.

The preceding advice in this chapter can help every man, whether he’s experiencing a problem or not. Remember: what’s good for your heart is good for your sexual health, and anything that improves your overall health will improve both your fertility and your sexual performance.

Understanding Semen Analysis

The male factor infertility is most commonly defined as abnormalities in the number of sperm present, proportion of the motile and morphologically normal sperm. WHO has defined normal values for human ejaculate.

Source

Volume

Characteristics

Urethral and bulbourethral glands

0.1-0.2cc

Viscous, clear

Testes, epididymides, vasa deferentia

0.1-0.2cc

Sperm present

Prostate

0.5-1.0cc

Acidic, watery

Seminal vesicles

1.0-3.0cc

Gelatinous, fructose positive

Complete ejaculate

2.0-5.0cc

Liquefies in 20-25min

Commonly Used Normal Semen Parameters

VOLUME

>2.0 ML

PH

7.2-7.8

CONCENTRATION

>20×106/ML

MOTILITY

>50%

MORPHOLOGY

>30% WITH NORMAL MORPHOLOGY

WBC

< 1×106/ML

Semen analysis is not a test for fertility. Fertility determination is a couple-related phenomenon that requires the initiation of a pregnancy. The patient cannot be considered fertile based only on normal semen analysis. It was shown that 30% of all patients with normal semen analysis have abnormal sperm function.

Semen specimen are obtained by masturbation into a sterile wide-mouth container after 2-5 days of abstinence and analyzed within 1 hour of collection. Therefore, the patients should be strongly recommended to collect samples within clinic area. If intercourse is the only way to collect sample, special nonreactive condoms are available.

Typically two to three semen analyses are obtained over a 3 month period prior to making any final conclusion regarding baseline sperm quality or quantity. However, if the first semen analysis is normal, the repeat test is not required. Recent febrile illness or exposure to gonadotoxic agents may affect spermatogenesis for up to 3 months, therefore semen analysis has to be postponed.

Normal ejaculate volume is between 2 and 6 ml. 65%of the volume is from seminal vesicles, 30-35% is from the prostate and only 5% from the vasa. Low volume is associated with absence or decrease of seminal vesicle component of ejaculate( absence of SV, complete or partial obstruction of ejaculatory ducts) or retrograde ejaculation

Normal semen pH is 7.2-8.0. Prostatic secretion is acidic while seminal vesicle fluid is alkaline (seminal fructose is derived from seminal vesicles). Acidic ejaculate (pH<7.2) may be associated with blockage of seminal vesicles. Infection is usually associated with alkaline ejaculate (pH >8.0_ Azoospermia with low ejaculate volume, fructose negative and acidic may imply obstruction of the ejaculatory ducts. pH over 8.0 may indicate infection. The semen is initially in liquefied state but quickly coagulate by the action of protein kinase secreted by the seminal vesicles. Proteolytic enzymes from the prostate liquefy coagulum in 20-25 minutes. Abnormal liquefaction may be cased by prostatic abnormalities, e.g. prostatitis. Increased viscosity may affect sperm motility

Concentration: Concentration: evaluated in Mackler or Cell-VU chambers. Azoospermic specimen contains no sperm, oligospermic specimen reveals concentration of less than 20×106 and normospermic specimen contains more than 20×106.

Motility and forward progression: normally >50% of sperm in the specimen are motile. Forward progression describes how fast the motile sperm are moving (normal 2+ in the scale from 0 to 4).

0

No movement

1

Movement, none forward

1+

Occasional movement of a few sperm

2

Slow, undirected

2+

Slow , directly forward movement

3-

Fast, but undirected movement

3

Fast, directed forward movement

3+

Very fast forward movement

4

Extremely fast forward movement

Morphology

shape of spermatozoa: Several techniques have been described to evaluate sperm morphology. Sperm are classified into normal-oval shaped, tapered, amorphous, duplicated and immature. Normal spermatozoid must have an oval form with smooth contour, acrosomal cap encompassing 40-70% of head, no abnormalities of midpiece, or tail and no cytoplasmic vacuoles of more than half of the sperm head. Head size is 5-6m M x 2.5-3.5m M. Any borderline sperm are counted as abnormal( amorphous, tapered,duplicated, immature, coiled tail, blunted tail, midpiece abnormalities). The predictive value of sperm morphology in determining pregnancy rates is low

WHO criteria: >30% normal forms ( 100 cells evaluated)

b.Strict criteria (higher predictive value in determining rates of pregnancy in IVF program) are based on the morphology of postcoital spermatozoa found at the level of the internal cervical os. 100 cells evaluated for only normal sperm (>14% normal forms). Men with fewer than 4% normal forms usually failed to fertilize without micromanipulation. Strict criteria for normal sperm morphology include:

White Blood Cells (WBC)

All semen samples have WBC in them. If greater than 1 million WBC per 1 ml are present, there is concern of infection. Generally leukocytospermia (WBC in the semen) affects 5-10% of the patient population, but can rise to 20% in certain patients groups. Semen has to be cultured for aerobic and anaerobic infection as well as Chlamydia and Mycoplasma. Additionally, leukocytes have to be differentiated from immature germ cells using immunohistochemical methods. WBC cells are deleterious because of their ability to stimulate the release of reactive oxygen species (ROS), thereby inhibiting sperm motility and sperm function. Reactive oxygen species (ROS) are produced by polymorphonuclear cells .The three main ROS are superoxide anion, hydrogen peroxide, and the hydroxyl radical. On the other hand, seminal plasma contains a number of antioxidants that protect sperm from oxidative damage from exposure to ROS. Men who have higher concentrations of such antioxidants may be able to tolerate greater concentrations of seminal leukocytes. Despite an apparently abnormal threshold level for leukocytes within the semen, a wide range of conflicting evidence exists as to the significance of seminal leukocytes and infertility. The impact of this condition and its treatment on semen quality are extremely controversial

Viability

Viability tests are used in cases of low motility to determine the presence of live sperm vs. necrozoospermia. The eosin test is based on the fact that eosin is excluded by live cells which are not stained. The tail of only live spermatozoa is swelling in the hypoosmotic solution (Hypoosmotic swelling test)

Fructose (13 mmol or more per ejaculate)

Fructose is androgen-dependent and is produced in the seminal vesicles. Fructose levels should be determined in any patient with azoospermia and especially in those whose ejaculate volume is less than 1 ml, suggesting seminal vesicle obstruction or atresia. Absence of fructose, low semen volume, and failure of the semen to coagulate indicate either congenital absence of the vas deferens and seminal vesicles or obstruction of the ejaculatory duct.

Semen analysis has comparatively limited predictive value for the ability of the individual to achieve pregnancy. Additionally, 10-20% of infertile couple will not have any abnormalities. In order to enhance the diagnostic power of semen analysis, new tests have been developed to identify functional defects and fertilizing potential of the sperm. The clinical data to support their use are not conclusive.

CASA- Computer Assisted Semen Analysis. Mostly for assessment of sperm concentration and specific patterns of sperm motility (velocity, linearity etc). The available clinical data show that the measurement obtained by CASA are correlated with conception in vivo and fertilization in vitro, but comprehensive quality control and quality assurance programs are necessary to ensure accuracy. The equipment is highly expensive.

Acrosome reaction. Absence of acrosome reaction implies poor prognosis for fertilization. The test for acrosome reaction is very expensive, labor intensive, subjective and not cost-effective since only 5% of infertile patients do not demonstrate an acrosome reaction.

Hamster egg penetration test to check sperm fusion ability. The diagnostic value is controversial because of difficulty in optimizing protocol. However, a zero test score may indicate a major impairment of sperm fusion capacity.

In Hemizona test (to evaluate sperm zona-binding capacity) the two halves of human zona pellucida is incubated with patient’s capacitated sperm and control fertile donor’s sperm.

PCR-based detection of the pathogens in the semen in patients with asymptomatic genital infection.

Biochemical markers e.g. Creatine Kinase, Reactive Oxygen Species.

Why It Is Done

A semen analysis is done to determine whether:

A man has a reproductive problem that is causing infertility

A vasectomy has been successful

The reversal of a vasectomy has been successful

How To Prepare

You may be asked to avoid any sexual activity that results in ejaculation for 2 to 5 days before a semen analysis. This helps ensure that your sperm count will be at its highest, and it improves the reliability of the test. If possible, do not avoid sexual activity for more than 1 to 2 weeks before this test, because a long period of sexual inactivity can result in less active sperm.

You may be asked to avoid drinking alcohol for a few days before the test.

Be sure to tell your health professional about any medications or herbal supplements you are taking.

How It Is Done

You will need to produce a semen sample, usually by ejaculating into a clean sample cup. You can do this in a private room or in a bathroom at your health professional’s office or clinic. If you live close to your health professional’s office or clinic, you may be able to collect the semen sample at home and then transport it to the office or clinic for testing.

The most common way to collect semen is by masturbation, directing the semen into a clean sample cup.

You can collect a semen sample during sex by withdrawing your penis from your partner just before ejaculating (coitus interruptus). You then ejaculate into a clean sample cup. This method can be used after a vasectomy to test for the presence of sperm, but other methods will likely be recommended if you are testing for infertility.

You can also collect a semen sample during sex by using a condom. If you use a regular condom, you will need to wash it thoroughly before using it to remove any powder or lubricant on it that might kill sperm. You may also be given a special condom that does not contain any substance that kills sperm (spermicide). After you have ejaculated, carefully remove the condom from your penis. Tie a knot in the open end of the condom and place it in a container that can be sealed in case the condom leaks or breaks.

If you collect the semen sample at home, the sample must be received at the laboratory or clinic within 1 hour. Keep the sample out of direct sunlight and do not allow it to get cold or hot. If it is a cold day, carry the semen sample container against your body to keep it as close to body temperature as possible. Do not refrigerate the semen sample.

Since semen samples may vary from day to day, 2 or 3 different samples may be evaluated within a 3-month period for accurate testing.

A semen analysis to test the effectiveness of a vasectomy is usually done 6 weeks after the vasectomy.

How It Feels

Producing a semen sample does not cause any discomfort. However, you may feel embarrassed about the method used to collect it. If masturbation is against your religious beliefs, discuss alternate methods of collection with your health professional.

Risks

There are no risks associated with collecting a semen sample.

Results

A semen analysis measures the amount of semen a man produces and determines the number and quality of sperm in the semen sample. Results of a semen analysis are usually available within a day. Normal values may vary from lab to lab.

Semen Analysis Certain Conditions May Be

Semen Volume

Normal

1.0–6.5 milliliters (mL) per ejaculation

Abnormal

An abnormally low or high semen volume is present, which may sometimes cause fertility problems.

Liquefaction Time

Normal

Less than 60 minutes

Abnormal

An abnormally long liquefaction time is present, which may indicate an infection.

Sperm Count

Normal

20–150 million sperm per milliliter (mL)0 sperm per milliliter if the man has had a vasectomy

Abnormal

A very low sperm count is present, which may indicate infertility. However, a low sperm count does not always mean that a man cannot father a child. Men with sperm counts below 1 million have fathered children.

Sperm Shape (morphology)

Normal

At least 70% of the sperm have normal shape and structure

Abnormal

Sperm can be abnormal in several ways, such as having two heads or two tails, a short tail, a tiny head (pinhead), or a round (rather than oval) head. Abnormal sperm may be unable to move normally or to penetrate an egg. Some abnormal sperm are usually found in every normal semen sample. However, a high percentage of abnormal sperm may make it more difficult for a man to father a child.

Sperm Movement (motility)

Normal

At least 60% of the sperm show normal forward movement. At least 8 million sperm per milliliter (mL) show normal forward movement.

Abnormal

Sperm must be able to move forward (or “swim”) through cervical mucus to reach an egg. A high percentage of sperm that cannot swim properly may impair a man’s ability to father a child.

Semen pH

Normal

Semen pH of 7.1–8.0

Abnormal

An abnormally high or low semen pH can kill sperm or affect their ability to move or to penetrate an egg.

White Blood Cells

Normal

No white blood cells or bacteria are detected.

Abnormal

Bacteria or a large number of white blood cells are present, which may indicate an infection.

Fructose Level

Normal

300 milligrams (mg) of fructose per 100 milliliters (mL) of ejaculate

Abnormal

The absence of fructose in the semen may indicate that the man was born without seminal vesicles or has blockage of the seminal vesicles.

Associated with a Low or Absent Sperm Count

These conditions include orchitis, varicocele, Klinefelter syndrome, radiation treatment to the testicles, or diseases that can cause shrinking (atrophy) of the testicles (such as mumps).

If a low sperm count or a high percentage of sperm abnormalities are found, further testing may be done. Other tests may include measuring hormones, such as testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), or prolactin. A small sample (biopsy) of the testicles may be needed for further evaluation if the sperm count or motility is extremely.

What Affects the Test

Factors that can interfere with your test or the accuracy of the results include:

Herbal medicines, such as St. John’s wort and high doses of echinacea.

A semen sample that gets cold. The sperm motility value will be inaccurately low if the semen sample gets cold.

Exposure to radiation, some chemicals (such as certain pesticides or spermicides), and prolonged heat exposure.

An incomplete semen sample. This is more common if a sample is collected by methods other than masturbation.

Not ejaculating for several days. This may affect the semen volume.

What To Think About

A semen sample collected at home must be received at the laboratory or clinic within 1 hour. Keep the sample out of direct sunlight and do not allow it to get cold or hot. If it is a cold day, carry the semen sample container against your body to keep it as close to body temperature as possible. Do not refrigerate the semen sample.

Consistently detecting sperm in the semen of a man who has had a vasectomy indicates that his surgery was not successful, and another form of birth control should be used to prevent pregnancy. A low number of sperm may be present in a semen sample taken initially after a vasectomy. However, sperm should not be present in subsequent samples.

A man whose mother took the medicine diethylstilbestrol (DES) during her pregnancy with him has a greater-than-normal risk of being unable to father a child (infertile).

Additional tests may include measuring hormone levels, such as testosterone, luteinizing hormone (LH), follicle-stimulating hormone (FSH), or prolactin. For more information, see the medical tests Testosterone, Luteinizing Hormone, Follicle-Stimulating Hormone, and Prolactin.

Other fertility testing, including sperm penetration, the presence of antisperm antibodies, or analysis after sexual intercourse (postcoital), may be recommended for infertility problems. For more information, see the medical test Infertility Testing.

Retrograde Ejaculation

Occurring in less than 1% of men with fertility problems, retrograde ejaculation can make it very difficult for a couple to conceive. While it has no health implications, men affected by this condition have their sperm diverted from their ejaculate to the bladder during orgasm.

Retrograde ejaculation can be caused by diabetes, prostate or bladder surgery, spinal cord injuries, or taking certain medications, like high blood pressure or mood altering medications. Because these conditions or medications can weaken the nerves in the bladder neck, the bladder fails to close during climax. Instead of exiting through the urethra as it would normally, the semen enters the bladder.

Signs of this condition include having cloudy urine after ejaculating, little to no semen during ejaculation and possibly infertility. Depending on the cause of the retrograde ejaculation, the condition may or may not be treatable. If certain medications are the reason for the ejaculatory problems, discontinuing their usage will often restore fertility.

However, when retrograde ejaculation is the result of a chronic condition or surgery, little can be done to treat it. Pregnancy may still be possible, though, through intracytoplasmic sperm injection and in vitro fertilization.

Definition

Retrograde ejaculation is when semen goes into the bladder rather than out of your penis during orgasm. Although you still reach sexual climax, you may ejaculate very little or no semen (dry orgasm). Retrograde ejaculation isn’t harmful, but it can cause fertility problems.

Retrograde ejaculation can be caused by medications, health conditions or surgeries that affect the nerves or muscle that control the bladder opening. If retrograde ejaculation is caused by a medication, stopping the medication may be effective. For retrograde ejaculation due to a health condition or as a result of surgery, treatment with medications may restore normal ejaculation and fertility.

What Is It?

Affecting less than 1% of infertile men, retrograde ejaculation refers to a condition whereby sperm flows backwards into the bladder, rather than forward and out of the body, during ejaculation. Normally during climax, the bladder neck is closed off to stop sperm from flowing into the bladder while at the same time preventing urine from mixing with the ejaculate.

In men that suffer from retrograde ejaculation, the nerves that help the bladder neck to close off are weakened, resulting in the failure to close off the bladder neck when a man orgasms. Therefore, semen enters into the bladder rather than exiting the body through the urethra.

Symptoms

Retrograde ejaculation does not affect your ability to get an erection or have an orgasm — but when you climax, semen goes into your bladder instead of coming out of your penis. Retrograde ejaculation can cause:

Dry orgasms or orgasms in which you ejaculate very little semen out of your penis

Urine that is cloudy after orgasm because it contains semen

Male infertility

Normally during ejaculation, sperm from the testicles is carried through a tube called the vas deferens until it mixes with fluid from the semen glands and prostate. The muscle at the opening of the bladder (bladder neck) should contract or tighten to prevent the semen from entering the bladder as it passes through the tube inside the penis (urethra). This is the same muscle that holds urine in your bladder until you urinate. With retrograde ejaculation, the bladder neck muscles don’t tighten properly. As a result, sperm can enter the bladder instead of being ejected out of the penis.

Causes

Several conditions can cause problems with the muscle that closes the bladder during ejaculation. These include:

Side effect of certain medications used to treat high blood pressure, prostate enlargement and mood disorders

Nerve damage caused by a medical condition such as diabetes, multiple sclerosis or a spinal cord injury

Retrograde ejaculation has several possible causes, including:

Damage from surgery to the muscles of the bladder, or to the nerves that control these muscles ? This damage can occur as a complication of the following surgical procedures:

Prostate surgery ? Men who have had a transurethral prostatectomy (removal of prostate tissue through the urethra) have a 10-15 percent chance of retrograde ejaculation. A prostatectomy (surgery to remove the entire prostate gland, either for cancer or benign enlargement) has a 40 percent to 90 percent chance of retrograde ejaculation after the procedure.

Surgery on certain parts of the bladder

Extensive pelvic surgery, especially to treat cancer of the prostate, testicles,colon or rectum

Staging surgery for cancer in the pelvis or lower abdomen (this surgery removes lymph nodes in the pelvis and lower abdomen to help determine how far cancer has spread)

Certain types of surgery on the discs and vertebrae of the lower spine

Nerve damage caused by medical illness?

This is especially common in men with multiple sclerosis or with long-term, poorly controlled diabetes.

Side effects of medication?

Certain medications can interfere with the function of nerves that control the muscles involved in ejaculation. They include:

Retrograde ejaculation does not interfere with a man’s ability to have an erection or to achieve orgasm, but it can cause infertility. because the sperm cannot reach the woman?s uterus. Retrograde ejaculation is responsible for about one percent of all cases of male infertility in the United States.

Risk Factors

You’re at increased risk of retrograde ejaculation if:

You have diabetes, especially if you have diabetic nerve damage

You have had prostate or bladder surgery

You take certain medications for high blood pressure or a mood disorder

You sustained a spinal cord injury

Complications

Retrograde ejaculation is not harmful. The only complication is difficulty getting your partner pregnant. Some men with retrograde ejaculation may find orgasm less pleasurable.

Tests And Diagnosis

To diagnose retrograde ejaculation, your doctor will look for sperm in your urine with a microscope after you ejaculate.

If you have a dry orgasm, but your doctor doesn’t find semen in your bladder, you may have a problem with semen production. This can be caused by damage to the prostate or semen-producing glands as a result of surgery or radiation treatment for cancer in the pelvic area

Prevention

If you need to have surgery that may affect the bladder neck muscle, such as prostate or bladder surgery, or if you have a spinal injury, there’s little you can do to prevent retrograde ejaculation. However, there are things you can do to prevent retrograde ejaculation caused by nerve damage from diabetes or the use of certain medications.

If you have diabetes, work with your doctor to keep your blood sugar under control.

If you’re taking medications for high blood pressure or a mood disorder, ask your doctor if they may cause retrograde ejaculation. You may be able to take another medication instead, or change doses.

In some cases, premature and inhibited ejaculation are caused by a lack of attraction for a partner, past traumatic events and psychological factors, including a strict religious background that causes the person to view sex as sinful. Premature ejaculation, the most common form of sexual dysfunction in men, often is due to nervousness over how well he will perform during sex. Certain drugs, including some anti-depressants, may affect ejaculation, as can nerve damage to the spinal cord or back.

Retrograde ejaculation is common in males with diabetes who suffer from diabetic neuropathy (nerve damage). This is due to problems with the nerves in the bladder and the bladder neck that allow the ejaculate to flow backward and into the bladder. In other men, retrograde ejaculation occurs after operations on the bladder neck or prostate, or after certain abdominal operations. In addition, certain medications, particularly those used to treat mood disorders, may cause problems with ejaculation. This generally does not require treatment unless it impairs fertility.

Treatment

Pure herbal treatment by Dr & Hakeem Tariq Mehmood Taseer to cure Retrograde ejaculation problem in males with well proven results. Has a very high success rate in treating different causes of this problem. Dosage and duration of the treatment may vary as per the patient profile. Treatment is without any side effects.

Increase Male Fertility

Roughly 35% of couples who have problems conceiving discover it is the man that has fertility problems and are looking at ways to increase male fertility.

Sperm counts have fallen by almost a third in the last 10 years. The main factors that seem to make a damaging dent on the man’s sperm count are an increase in drug use, alcohol consumption, smoking and an increase in obesity.

In isolation these factors are bad enough, but when two or more of these causes are combined it leads to a rapid decline in the number and quality of sperm.

Tips To Improve Male Fertility

But don’t despair! If you’re thinking of conceiving, here are some quick and easy tips for turning yourself into a literal sperm making machine.

Eat brazil nuts – Brazil nuts are rich in selenium, a mineral that seems to help boost sperm production and improve their swimming ability.

Eat tomatoes – Research suggests that lycopene, a nutrient found in tomatoes, helps in the production of healthy, agile sperm.

Deal with your stress – Stress leads to the release of adrenalin and other hormones which can restrict blood flow to the testes and inhibit sperm production. It also leads to the release of chemical by-products called free radicals, which lead to sperm damage. Take an anti-oxidant supplement with zinc, selenium and vitamin C.

Take vitamins – Studies show that supplementing with vitamin C can assist in the making of properly functioning sperm, and reduce their tendency to clump together (agglutinate). 1,000mg of vitamin C each day should be enough to help men make top seed. High doses of zinc appear to help boost levels of testosterone in men with low levels of this hormone, and may bring substantial improvements in sperm numbers. A zinc supplement of 50-100mg should be taken each day (balanced with 3-6mg of copper per day to prevent copper deficiency) for three months. Like zinc, Korean ginseng appears to have the ability to enhance both testosterone and sperm levels. About 500mg of standardised extract should be taken each day for three months.

Eat healthy fats – Healthy fats, known as essential fatty acids (EFAs), appear to be important ingredients in the manufacture of sperm. The Total EFA is a supplement that contains a range of EFAs that may help boost sperm numbers in time.

Go organic – Declining sperm counts could be related to xenoestrogens, hormone-like chemical pollutants that come from a variety of sources, including agrochemical residues. A shift towards more organic foods in the diet will help to reduce exposure to these fertility-sapping chemicals.

Stay cool – Testicles should remain cooler than the rest of the body, so tight Y-fronts, hot baths and high central heating temperatures are a no-no. Men are also advised to walk about after sitting at a computer to help the airflow around the testes.

Avoid recreational drugs – Cocaine, for example, affects sperm motility and could prevent fertilisation. Cannabis leads to a low sperm count and an increase in abnormal sperm. Smoking one joint lowers testosterone levels for up to 36 hours. Avoid muscle-building drugs, too. Anabolic steroids, taken by some athletes to increase muscle size, and improve strength and endurance, may boost sex drive and sexual performance in the short term. But in the long term, they have the opposite effect and can cause a 25 per cent drop in sperm count

Reduce or completely eliminate alcohol. Alcohol can effect the production of normally developed, healthy sperm.

Keep your testicles cool. Excessive exercise, tight underwear, hot tubs or anything that raises the temperature of the scrotum should be avoided.

Stop using anabolic steroids. A major cause of infertility, anabolic steroids can permanently shrink the testes and cause infertility.

Stock up on vitamin C and zinc. Taking vitamin and zinc supplements has been shown to increase sperm mobility and reproductive health in general.

Ask your doctor if any antibiotic you are taking could effect sperm count and motility. Change the antibiotic if you are trying to conceive.

Eat well and get proper nutrition. Bad eating habits may contribute to infertility.

Have sex with your partner several times a day. New research suggests that rather than waiting several days to have intercourse, daily sex can increase the chances of conception.

Relax. Stress plays an important role in infertility in men and women so find ways to relax, hopefully with your partner.

The likelihood of a woman becoming pregnant is much higher when you have intercourse in the three days immediately leading up to and including ovulation. Some experts call these three days the “fertile window.” You can determine when a woman ovulates either by using a basal temperature chart, or with an over-the-counter ovulation predictor kit.

The frequency of intercourse during the fertile window generally doesn’t matter. Although earlier studies seemed to show that several days of abstinence might increase sperm counts, more recent findings indicate that more frequent intercourse may in fact be better.

Contrary to popular belief there is no scientific evidence of a “best position” for conception. However, having the woman stay in bed with her hips elevated for half an hour after intercourse may be helpful.

Fertility Health For Men

Taking Charge of Your Fertility

When a couple experiences problems trying to conceive, it is just as likely to be due to male problems as it is to female problems. Causes of male infertility are numerous but there are some things that a man can do to help increase his chances of having a child.

Live Long and Prosper

Diet and exercise are important factors behind a person’s quality of health. A diet of fast food, processed food, and just plain junk food that is all too common these days does not provide you with the nutrients that you need to stay healthy.

Eating lots of fruits and vegetables along with low-fat dairy and protein gives your body the vitamins it needs to function properly, which includes the production of sperm. Additionally, eating those fatty, high calorie foods is more likely to lead to being overweight and even obese, which recent studies have shown to be a factor in male infertility.

In combination with improving their diet, reducing stress and exercising more, men are also turning to fertility supplements for help. Made of all-natural ingredients, supplements can increase sperm motility and sperm count, help to strengthen the male reproductive system plus increase sex drive and virility.

Exercise Regularly

Regular exercise (at least three times a week for at least 30 minutes each time) can help you maintain your weight and encourages optimal health. For those that are overweight or obese, losing weight will not only help your body produce healthier sperm, but it can also improve the quality of your sex life. And having a better sex life is a sure fire way to get your partner pregnant.

But before you start having visions of being the next Body Builder Champion, be realistic in your exercise. Bulking up through the use of steroids may make you look like Superman but it will also make you impotent, which is probably why Superman never had any children. You may also want to avoid using the sauna after your workout. Prolonged exposure to heat can interfere with your ability to produce sperm.

Cut Out Smoking; Cut Down On Drinking

Other lifestyle factors that affect the quality of a man’s sperm include cigarettes and alcohol consumption. Just as women must cut out these vices when they are trying to conceive, so must men.

Compared to a non-smoker, a man who smokes has a lower sperm count and a greater number of misshapen sperm, neither of which is very conducive to creating a child. Additionally, heavy or binge drinking (four or more alcoholic drinks in one evening) can seriously affect your ability to produce quality sperm. Recreational drug use should also be cut out of your life as drugs like marijuana can kill off your sperm.

Other Toxins

And don’t think that it is just what you put into your mouth that will affect your sperm. Rogaine may give you the hope of having a full head of hair again some day but it will also interfere with your sperm quality. You may want to put off getting your hair back while you and your partner are trying to conceive. Other environmental toxins, like pesticides, can also damage your sperm, so try to limit your exposure to them.

A Historical Impact

Looking back over the years, have there been other men in your family that have experienced fertility problems? If so, then it may not be so unusual that you are experiencing difficulty getting pregnant with your partner as some male fertility problems may be genetic. If there have never been any problems, then take another trip down memory lane and try to remember if you ever had any surgery done, specifically to your groin or abdominal areas. Having surgery can produce scar tissue on your reproductive organs, which can block sperm from traveling along their desired path. The surgery may have even damaged parts of your reproductive system, making it difficult for you to produce sperm.

If you have any health problems, then this could be the source of your fertility problems. In some instances, it is the health issue itself that causes infertility, while in other cases it is the medication used to treat the issue that hinders the production or quality of sperm. Additionally, past illnesses, like mumps, may have actually shrunk your testicles, which in turn, slows down the production of sperm.

Visiting The Doctor

When you and your partner have been trying unsuccessfully to conceive for a year, it is probably time to book an appointment with an infertility specialist. If your partner is over 40, then make that appointment after trying for six months. Along with testing your partner, the fertility specialist will analyze the quality of your sperm, evaluating the volume of your ejaculation as well as the density, shape and motility of the sperm.

For some men, it can be difficult to admit they have a fertility problem. To them, their virility is a sign of their masculinity. However, it is important to remember that many couples experience fertility problems at some point. Seeing a specialist can help you identify just what is wrong and get you started on solving the problem

A Man’s Fertility

8 Ways to Improve Male Fertility

Having a less-than-optimal sperm count isn’t the end of the world. While conceiving may be a little more difficult, there are ways to improve your fertility before seeking expensive treatments. Hopeful dads can take these steps to improve their chances of making a baby:

Limit or discontinue all drugs (OTC, prescription and “street” drugs).

Certain ulcer medications and steroids can suppress sperm production, and recreational drugs like tobacco, alcohol and marijuana can have the same effect.

It makes sense to wear loose-fitting underwear if you are trying to keep the temperature of your testicles down. If they are pulled up to your body, they will be warmer than if they hang away from you.

Limit your time on the bicycle.

If you have been diagnosed with a low sperm count, limit your bike riding time. The friction and jostling can cause temperature rises and possible injury.

Eat a good diet and get enough zinc.

Studies have shown that some men with a zinc deficiency have a lowered sperm count.

Limit intercourse.

Limit sex to every other day instead of every day during your partner’s fertile cycle. While it is not necessary for every couple to follow this rule, men who are known to have lower sperm counts should not be releasing semen every day because they need a chance to replenish their already low supply.

Refrain from oral sex.

Saliva can actually kill sperm. Similarly, most lubricants can also kill sperm and should be avoided.

Get tested for lead and other chemicals.

If you work in a contaminated industrialized area, you should get tested for lead and other chemicals. Lead, chromium, ethylene glycol ethers and other chemicals can decrease sperm count and cause abnormal sperm.

While following these recommendations won’t guarantee success, it will give you a head start on your journey to conception. Chances are, many infertility specialists will recommend that you take these steps before they attempt to treat your low sperm count.

Evaluation of the Male for Infertility

Infertility is a major health concern for a large proportion of reproductive age patients. The purpose of this article is to give a concise but practical overview of the evaluation of the infertile man because approximately 40 % of infertility cases involve male factors. Significant medical pathology can now be uncovered by a comprehensive infertility evaluation of the man. Advances in the understandings and diagnoses of male factor infertility is advancing at a rapid pace. The man must not be ignored, and the following information is a guide to his evaluation.

Evaluation

The initial workup begins whenever the patient presents. This is predicted by the fact that the longer a couple remains infertile the less chance there is for cure. A rapid, noninvasive, cost-effective evaluation is essential.

History

The cornerstone of the evaluation of the infertile man is the history and physical examination. Table1 outlines the complete pertinent history. The sexual history is paramount. Some of the problems most commonly encountered in this patient population are related to the timing of intercourse, with it being too frequent or too infrequent. The history of an undescended testicle is significant. In a patient with a history of unilateral cryptorchidism, regardless of the time of orchidopexy, overall semen quality is considerably less than that found in normal men.

Bilateral cyrptorchidism is extremely important. Progressive damage occurs to the germinal epithelium if the testicle is not in its proper position in the scrotum. It has been shown that orchidopexy should be performed prior to 2 years of age to maintain a significant level of spermatogenic function. Any previous surgery of the retroperitoneum, bladder neck (prostate), pelvis, inguinal region, or scrotum should be assessed. Any surgery on the bladder neck may cause retrograde ejaculation. Inguinal surgery such as herniorrhaphy, undertaken when an infant or an adult, may have caused vassal occlusion or vascular insufficiency to the testicule. Fever can cause impaired testicular function. The ejaculate may not be affected for more than 3 months after the event, as spermatogenesis takes about 74 days. Postpubertal mumps may cause mumps orchitis, which results in an atrophic testis. Fifty percent of patients with testicular cancer have subnormal sperm densities prior to therapy. A history of diabetes or multiple sclerosis should raise questions about potency and ejaculatory function. Exposure to drugs and toxins should be detailed. The routine use of hot tubs or saunas should be discontinued, as elevated temperatures impair spermatogenesis. A family history of cystic fibrosis is important owing to associated vassal agenesis and epididymal abnormalities. Finally, a history of anosmia (lack of smell) indicates the possibility of hypogonadotropic hypogonadism. Galactorrhea, head-aches, and impaired visual fields suggest the presence of a central nervous system tumor.

Infertility History

1) SEXUAL HISTORY

3) PAST SURGICAL HISTORY

Duration of infertility

Previous treatments

Potency surgery

Timing and frequency of intercourse

Orchietomy

Orchidopexy

Retroperitoneal surgery

Pelvic, inguinal or scrotal surgery

Herniorrhaphy

2) PAST MEDICAL HISTORY

4) MEDICATIONS AND GONADOTOXINS

Undescended testicles

Testicular torsion / trauma

Delayed puberty

Pelvic injury

Diabetes

Previous or current therapy

Viral and febrile illness history

Postpubertal mumps orchitis

Sexually transmitted diseases

Urinary tract infections

Cystic fibrosis, or family history of it

Chemotherapeutic agents

Therapeutic drugs

Chemicals (pesticides)

Recreational drugs :smoking, marijuana,cocaine

Androgenic steroids

Thermal exposure (hot tubs)

Radiatio

Physical Examination

The physical examination must be thorough, with special attention to the genitalia. The penile curvature and location of the urethral meatus should be assessed, as abnormalities may result in improper delivery of the ejaculate. Testicular size and consistency must be recorded, with the length measured with calipers and the volume estimated with an orchidometer. Size is an important indicator of spermatogenic capability, as more than 80 % of the testis is involved in sperm production. When there is damage to the testicular tubules, loss of mass occurs. The normal length of the testis is about 4 cm and the volume more than 20 ml. Epididymal induration and irregularities should be noted. The presence of a vas must be documented, as 2 % of infertile men have congenital absence of the vas. Varicoceles, that is, dilated spermatic veins that present, as a “bag of worms” above the testicle in the scrotum must be identified. A varicocele can cause abnormalities in gonadal function. The scrotal contents should be palpated with the patient in both the supine and standing positions. Many varicoceles are not visible and may be discernible only when the patient stands or performs a Valsalva maneuver. Varicoceles often result in a smaller testis on that side. Ninety percent are left-sided, and any discrepancy in size between the two testes should arouse suspicion of a varicocele. A rectal examination is essential to assess prostate size, evidence of infection, and the presence of midline cysts. Look carefully for signs of hypogonadism, such as decreased body hair, gynecomastia, infantile genitalia, and decreased muscular development.

Laboratory Evaluation

The laboratory is an integral part of a full-service infertility center. If an on-site laboratory is not available, specimens must be analyzed by a dedicated infertility laboratory. Data from a reputable laboratory are critical . Unfortunately, the semen analysis must be done locally because the specimen must be evaluated shortly after production. Most other studies can be sent out to any reputable laboratory.

Semen Analysis

The primary laboratory test is the semen analysis. It must be emphasized that semen analysis is not a test for fertility. It does not separate patients into sterile and fertile groups; it does give diagnostic information and allows a directed evaluation and treatment. At least two semen analyses must be obtained to establish a baseline. The standard semen analysis allows evaluation of semen volume, pH, density (sperm per milliliter), motility, measurement of forward progression of sperm, and sperm morphology. The semen is examined also for evidence of sperm agglutination, hyperviscosity, and the presence of white blood cells. The World Health Organisation (WHO) range of values for normal semen analysis is given in

WHO(1999) CRITERIA FOR NORMAL SEMEN ANALYSIS

SEMEN PARAMETER

VALUE

Volume

2.0 –5.0 ml

Density

> 20 million/ml

Motility

> 50 %

Forward progression

> 2 (scale 1 – 4)

Morphology

> 30% normal forms

Leukocytes

< 1 million / ml

Agglutination

None

Hyperviscosity

None

Some laboratories use computer-assisted semen analyses, which are of some value for measuring sperm motility, however, they should be used only as a source of supplemental information. Attention has been turned to a more accurate manual analysis of sperm morphology.

Leukocytes In The Semen

Leukocytes in semen have significant effects on sperm function. They modulate an autoimmune response, adversely affect motility and fertilizing capacity, and deter sperm transport in the female reproductive tract. The semen of most men contains some immature sperm forms (round cells), which ordinarily cannot be distinguished form white blood cells (WBCs).

This often leads to an erroneous diagnosis of pyospermia or infection. Semen cultures are not indicated in asymptomatic patients, as they are essentially always negative. Routine cultures for a typical organisms are unwarranted because they are not always accurate, are labor- and cost-prohibitive, and have not been shown to have a clinical impact. For the few patients with symptoms of urinary or genital tract infections cultures should be prepared. The specific cultures obtained depend on the individuals ‘symptoms’ and examination but should include cultures of urine, expressed prostatic secretions, and a postprostatic massage urine sample. Common sexually transmitted organisms such as Chlamydia, Mycoplasma and Ureaplasma have been implicated in reproductive failure. Patients with active prostaititis or other urinary tract infections frequently have decreased sperm count and motility.

Fructose In The Semen

With low-volume oligospermia or low-volume azoospermia, one should be concerned about retrograde ejaculation and ejaculatory duct obstruction.

The assessment for ejaculatory duct obstruction may incorporate a test for seminal fructose, a sugar produced in the seminal vesicles. Its absence may indicate the possible absence of the seminal vesicles or obstruction of the ejaculatory ducts.

Anti-Sperm Antibodies

The incidence of anti-sperm antibodies in the infertile man range from 8 % to 21 %. In men only antibodies present on the sperm surface are clinically important.

Anti-sperm antibodies have implications at various stages in the fertilization process, that is, due to poor sperm penetration into cervical mucus; impaired acrosome reaction and zona binding. Risk factors for the development of sperm-bound antibodies include previous testicular surgery, trauma, or infection, as does a history of torsion, cryptorchidism and genitourinary infections. Additionally, obstructive azoospermia (possibly due to obstruction from a previous hernia repair, congenital absence of the vas deferens, or vasectomy) can induce sperm autoimmunity.

The test is based on the principle of hypo-osmotic solutions being passively transferred across intact cell membranes. Sperm with functionally intact cell membranes swell and their tails undergo coiling when exposed to hypo-osmotic conditions. There is a high degree of correlation between the results of swelling test and fertilizing capacity as measured by the sperm penetration assay.

Acrosome Intactness Test: The acrosome contains a number of enzymes which help human spermatozoa penetrate the outer investments of the ovum. Several functional and ultrastructural acrosomal defects that lead to male infertility have been reported. Acrosome Intactness Test evaluates the functional status of the acrosome and serves as a good indicator of sperm’s ability to penetrate the oocyte’s investments. The test is based on the ability of the proteolytic enzymes of the acrosome to dissolve gelatin when sperm are placed over a gelatin coated slide.

Sperm Nuclear Chromatin Decondensation Test: One of the early events of fertilization following the sperm penetration with the egg is the decondensation of the sperm nuclear chromatin. Sperm with defective heads don’t decondense and are dysfunctional. This test helps in determining the incidence of sperm with defective heads. The test is based on the principle of sodium dodecyl sulphate (SDS) and ethyl diamine tetra acetic acid’s (EDTA) ability to permeate the sperm head membrane and chelate the zinc protecting the disulfide linkages between the nuclear proteins. Exposure of sperm to these compounds facilitates the in vitro decondensation of nuclear chromatin and thus aids in identifying sperm whose nuclei lack the ability to decondense.

Sperm Mitochondrial Activity Indices (Smai): Respiratory enzyme present in the mitochondria provide energy for sperm motility. The presence of these enzymes can be identified by the Nitroblue Tetrazolium (NBT) reaction. This dye when exposed to mitochondrial enzymes, gets reduced and precipitates to form a blue black compound called formazan. The intensity of the reaction and distribution of formazan are used to determine SMAI which is indicative of the functional status of the sperm mitochondria. Lack of mitochondrial enzymes impair sperm motility and may cause infertility.

Sperm-Cervical Mucus Interaction: The postcoital test assesses the sperm in the partner’s cervical mucus and the interaction between the two. The test is performed just prior to ovulation. A specimen of cervical mucus, obtained within a few hours of intercourse, is examined under a microscope. More than 10 sperm per high power field, most of which demonstrate progressive motility, constitutes a normal study. Indications for postcoital testing include hyperviscous semen, unexplained infertility and low-volume semen with good sperm density. This test is contraindicated for patients with poor quality semen specimens. Inherent poor reproducibility and the fact that there are specimens from both parties make the study difficule to interpret. If an abnormal result is obtained, an in vitro cervical mucus penetration test may be performed. These tests have been developed to standardize and isolate semen factors.

Sperm Penetration Assay: The sperm penetration assay is a sophisticated test that measures the physiologic ability of the human sperm to enter a zona-free hamster egg and begin the fertilization reaction. The zona pellucida is the barrier to cross-species fertilization. When hamster eggs are rendered zona-free and penetrated by human spermatozoa in vitro, they serve as a substitute for human ova in a preliminary assessment of fertilizing capacity. For successful penetration, sperm must be able to undergo capacitation, the acrosome reaction, fusion with the oolema and incorporation into the ooplasm. Scoring is based on the percentage of ova penetrated, or number of penetrations per ovum. The lower limit of normal is 10 – 30 % of ova penetrated.

Hormonal Screening

A brief review of male reproductive endocrine physiology is essential. The testes are dual organs. There is an endocrine (hormonal) component consisting of Leydig cells, Sertoli cells, and germ (sperm) cells. This component is necessary for male sexual differentiation and maturation, normal potency and ejaculatory capability, and spermatogenic maturation.

Endocrine and spermatogenic compartments are anatomically and functionally integrated. Proper hormone balance is initiated by a pulsatile hypothalamine release of gonadotropin releasing hormone (GnRH). This causes pituitary release of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which have a direct action on the testis. FSH acts on Sertoli cells to provide a favorable milieu for spermatogenesis. LH stimulates the Leydig cell to secrete testosterone, providing the locally high concentration required for spermatogenesis. Serum testosterone reflects Leydig cell function and provides an indication for intratesticular testosterone. Table No.3 depicts the various hormonal patterns and their corresponding clinical entities.

Hormonal Patterns And Corresponding Clinical Status

CLINICAL STATUS

FSH

LH

T

Normal

Normal

Normal

Normal

Testicular failure

Elevated

Elevated

Normal or Low

Germinal aplasia

Elevated

Normal

Normal

Hypogonadotropic hypogonadism

Low

Low

Low

Diagnostic Studies

Scrotal Ultra sonography

The use of ultrasonography to image organs and vessels and to measure blood flow is beneficial during evaluation of the infertile man. Its principal application regarding male factor infertility is for the diagnosis of varicoceles.

The diagnosis is based on a venous diameter of 3.5 mm or more with the patient at rest so he can be scanned in the supine position. Subclinical varicoceles are approximately 3 mm in diameter. Color flow Doppler allows determination of the direction and magnitude of blood flow. To detect the change in flow, or reflux, the patient must perform the Valsalva maneuver and may require examination in the standing position. This positioning allows adequate assessement of reflux in the testicular veins, although the accuracy and clinical significance are not absolute. Scrotal ultrasonography and color duplex Doppler are excellent adjuncts in patients with equivocal examinations.

Transrectal Ultrasonography

Transrectal ultrasonography (TRUS) is now being used to detect varying degrees of ejaculatory duct obstruction. It is essentially a noninvasive, inexpensive office procedure that is readily available. Ejaculatory duct obstruction is easily diagnosed, and the results are highly accurate when using TRUS in azoospermic patients with low ejaculate volume. Obstruction is documented by the presence of dilated seminal vesicles more than 1.5 cm in diameter seen on transverse imaging. Additional findings indicating obstruction include midline intraprostatic cystic structures and intraprostatic calcifications along the projected course of the ejaculatory ducts. The absence of seminal vesicles and ampulla of the vas is diagnostic of congenital abnormalities.

Postejaculate Urinalysis

A postejaculate urinalysis to detect retrograde ejaculation should be obtained in patients with anejaculation (no antegrade ejaculate), those with low-volume azoospermia, and all others with low-volume semen samples, including those with oligospermia and normal concentration. The patient voids to completion, produces anejaculate and then immediately voids into a specimen container. The unspun voided specimen is then evaluated. A diagnosis of retrograde ejaculation is confirmed when more than 10 sperm are noted per high power field

Testis Biopsy

Testis biopsy is reserved for patients who have azoospermia, essentially normal-size testes, palpable vas deferens and epididymis and a normal volume of semen. In these cases, testis biopsy allows the differentiation between patients with microtubular obstructive disease who are candidates for microsurgical repair and patients with disorders of sperm development.

Testicular biopsy can be performed in the office under local anesthesia. Plain I % lidocaine is used to infiltrate the anterior scrotal skin and dartos layers. With the testicle firmly held in position and the anterior surface up against the scrotal wall, a 1 cm incision is made down to the tunica vaginalis. Holding stitches are placed in the tunica vaginalis and it is opened sharply the length of the incision. An eyelid retractor is placed and additional 1 % lidocaine is dripped on the the tunica albuginia. A holding stitch is placed in the tunica albuginia, which is then incised approximately 0.5 – 1.0 cm in length. Testicular tubules extrude from the opening and are excised with tenotomy scissor. The tissue is placed in support medium, such as human tubular fluid or Ham’s F-10, for transport to the laboratory. The biopsy is best done where intravenous sedation can be administered. Testicular biopsy remains the gold standard in regard to diagnosis when one is searching for a small number of sperm. With the current use of the Johnson Scoring Technique when reading testicular biopsies, it has become a method of good prognostic value as it afforded a quantitative evaluation of germ cells and leydig cells over and above routine microscopic study. Additionally it permits evaluation of vassal patency, the status of the epididymis and surgical treatment of a varicocele if this was diagnosed per operatively.

Results Of Evaluation

Evaluation of the infertile male categorizes patients. Not only can diagnoses be made (see Table No.4) treatment plans can be discussed and initiated. Both partners should be present during the initial visit and any subsequent visit during which treatment decisions are made. Each case must be individualized with male partner issues, female partner issues, success rates for treatment options, costs, morbidities, and the couple’s expectations being addressed.

Diagnoses After Evaluation

Diagnosis

Patients (%)

Varicocele

37 – 42

Idiopathic

20 – 25

Obstruction

6 – 14

Anti-sperm antibodies

3 – 9

Testicular failure

1 – 9

Pyospermia/infection

1 – 5

Ejaculatory dysfunction

1 – 3

Endocrinopathies

1

Male Reproductive Physiology

The Hypothalamic-Pituitary-Gonadal Axis

The hypothalamus is the integrative center of the reproductive axis and receives messages from both the central nervous system and the testes to regulate the production and secretion of gonadotropin releasing hormone (GnRH).

Neurotransmitters and neuropeptides have both inhibitory and stipulatory influence on the hypothalamus. The hypothalamus releases GnRH in a pulsatile nature which appears to be essential for stimulating the production and release of both luteinizing hormone (LH) and follicle stimulating hormone (FSH). Interestingly and paradoxically, after the initial stimulation of these gonadotropins, the exposure to constant GnRH results in inhibition of their release. LH and FSH are produced in the anterior pituitary and are secreted episodically in response to the pulsatile release of GnRH. LH and FSH both bind to specific receptors on the Leydig cells and Sertoli cells within the testis. Testosterone, the major secretory product of the testes, is a primary inhibitor of LH secretion in males. Testosterone may be metabolized in peripheral tissue to the potent androgen dihydrotestosterone or the potent estrogen estradiol. These androgens and estrogens act independently to modulate LH secretion. The mechanism of feedback control of FSH is regulated by a Sertoli cell product called inhibin. Decreases in spermatogenesis are accompanied by decreased production of inhibin and this reduction in negative feedback is associated with reciprocal elevation of FSH levels. Isolated increased levels of FSH constitute an important, sensitive marker of the state of the germinal epithelium.

Prolactin also has a complex inter-relationship with the gonadotropins, LH and FSH. In males with hyperprolactinemia, the prolactin tends to inhibit the production of GnRH. Besides inhibiting LH secretion and testosterone production, elevated prolactin levels may have a direct effect on the central nervous system. In individuals with elevated prolactin levels who are given testosterone, libido and sexual function do not return to normal as long as the prolactin levels are elevated.

The Testes

Leydig Cells

Testosterone is secreted episodically from the Leydig cells in response to LH pulses and has a diurnal pattern, with the peak level in the early morning and the trough level in the late afternoon or early evening. In the intact testis, LH receptors decrease or down-regulate after exogenous LH administration. Large doses of GnRH or its analogs can reduce the numbers of LH receptors and therefore inhibit LH secretion. This has been applied clinically to cause medical castration in men with prostate cancer. Estrogen inhibits some enzymes in the testosterone synthetic pathway and therefore directly effects testosterone production. There also appears to be an intratesticular ultra short loop feedback such that exogenous testosterone will override the effect of LH and inhibit testosterone production. In normal males, only 2% of testosterone is free or unbound. 44% is bound to testosterone-estradiol-binding globulin or TeBG, also called sex hormone-binding globulin. 54% of testosterone is bound to albumin and other proteins. These steroid-binding proteins modulate androgen action. TeBG has a higher affinity for testosterone than for estradiol, and changes in TeBG alter or amplify the hormonal milieu. TeBG levels are increased by estrogens, thyroid administration and cirrhosis of the liver and may be decreased by androgens, growth hormone and obesity. The biological actions of androgens are exerted on target organs that contain specific androgen receptor proteins. Testosterone leaves the circulation and enters the target cells where it is converted to the more potent androgen dihydrotestosterone by an enzyme 5-alpha-reductase. The major functions of androgens in target tissues include 1) regulation of gonadotropin secretion by the hypothalamic-pituitary axis; 2) initiation and maintenance of spermatogenesis; 3) differentiation of the internal and external male genital system during fetal development; and 4) promotion of sexual maturation at puberty.

Seminiferous Tubules

The seminiferous tubules contain all the germ cells at various stages of maturation and their supporting Sertoli cells. These account for 85-90% of the testicular volume. Sertoli cells are a fixed-population of non-dividing support cells. They rest on the basement membrane of the seminiferous tubules. They are linked by tight junctions.

These tight junctions coupled with the close approximation of the myoid cells of the peritubular contractile cell layers serve to form the blood-testis barrier. This barrier provides a unique microenvironment that facilitates spermatogenesis and maintains these germ cells in an immunologically privileged location. This isolation is important because spermatozoa are produced during puberty, long after the period of self-recognition by the immune system. If these developing spermatozoa were not immunologically protected, they would be recognized as foreign and attacked by the body’s immune system. Sertoli cells appear to be involved with the nourishment of developing germ cells as well as the phagocytosis of damaged cells. Spermatogonia and young spermatocytes are lower down in the basal compartment of the seminiferous tubule, whereas mature spermatocytes and spermatids are sequestered higher up in the adluminal compartment.

The germinal cells or the spermatogenic cells are arranged in an orderly manner from the basement membrane up to the lumen. Spermatogonia lie directly on the basement membrane, and next in order, progressing up to the lumen, are found the primary spermatocytes, secondary spermatocytes and spermatids. There are felt to be 13 different germ cells representing different stages in the developmental process.

Spermatogenesis is a complex process whereby primitive stem cells or spermatogonia, either divide to reproduce themselves for stem cell renewal or they divide to produce daughter cells that will later become spermatocytes. The spermatocytes eventually divide and give rise to mature cell lines that eventually give rise to spermatids. The spermatids then undergo a transformation into a spermatozoa. This transformation includes nuclear condensation, acrosome formation, loss of most of the cytoplasm, development of a tail and arrangement of the mitochondria into the middle piece of the sperm which basically becomes the engine room to power the tail. Groups of germ cells tend to develop and pass through spermatogenesis together. This sequence of developing germ cells is called a generation. These generations of germ cells are basically in the same stage of development. There are six stages of seminiferous epithelium development. The progression from stage one through stage six constitutes one cycle. In humans the duration of each cycle is approximately 16 days and 4.6 cycles are required for a mature sperm to develop from early spermatogonia. Therefore, the duration of the entire spermatogenic cycle in humans is 4.6 cycles times 16 days equals 74 days.

Hormonal Control of Spermatogenesis

An intimate structural and functional relationship exists between the two separate compartments of the testis, i.e. the seminiferous tubule and the interstitium between the tubules. LH effects spermatogenesis indirectly in that it stimulates androgenous testosterone production.

FSH targets Sertoli cells. Therefore, testosterone and PSH are the hormones that are directed at the seminiferous tubule epithelium. Androgen-binding protein which is a Sertoli cell product carries testosterone intracellularly and may serve as a testosterone reservoir within the seminiferous tubules in addition to transporting testosterone from the testis into the epididymal tubule. The physical proximity of the Leydig cells to the seminiferous tubules and the elaboration by the Sertoli cells of androgen-binding protein, cause a high level of testosterone to be maintained in the microenvironment of the developing spermatozoa. The hormonal requirements for initiation of spermatogenesis appear to be independent of the maintenance of spermatogenesis. For spermatogenesis to be maintained like for instance after a pituitary obliteration, only testosterone is required. However, if spermatogenesis is to be re-initiated after the germinal epithelium has been allowed to regress completely, then both FSH and testosterone are required.

Transport-Maturation-Storage of Sperm

Although the testis is responsible for sperm production, the epididymis is intimately involved with the maturation, storage and transport of spermatozoa. Testicular spermatozoa are non-motile and were felt to be incapable of fertilizing ova. Spermatozoa gain progressive motility and fertilizing ability after passing through the epididymis.

The coiled seminiferous tubules terminate within the rete testis, which in turn coalesces to form the ductuli efferentes. These ductuli efferentes conduct testicular fluid and spermatozoa into the head of the epididymis. The epididymis consists of a fragile single convoluted tubule that is 5-6 meters in length. The epididymis is divided into the head, body, and tail. Although epididymal transport time varies with age and sexual activity, the estimated transit time of spermatozoa through the epididymis in healthy males is approximately four days. It is during the period of maturation in the head and body of the epididymis that the sperm develop the increased capacity for progressive motility and also acquire the ability to penetrate oocytes during fertilization. The epididymis also serves as a reservoir or storage area for sperm. It is estimated that the extragonadal sperm reservoir is 440 million spermatozoa and that more than 50% of these are located in the tail of the epididymis. The sperm that are stored in the tail of the epididymis enter the vas deferens which is a muscular duct 30-35 cm in length. The contents of the vas are propelled by peristaltic motion into the ejaculatory duct. Sperm are then transported to the outside of the male reproductive tract by emission and ejaculation.

During emission, secretions from the seminal vesicles and prostate are deposited into the posterior urethra. Prior to ejaculation peristalsis of the vas deferens and bladder neck occur under sympathetic nervous control. During ejaculation, the bladder neck tightens and the external sphincter relaxes with the semen being propelled through the urethra via rhythmic contractions of the perineal and bulbourethral muscles. It is true that the first portion of the ejaculate contains a small volume of fluid from the vas deferens which is rich in sperm. The major volume of the seminal fluid comes from the seminal vesicles and secondarily the prostate. The seminal vesicles provide the nourishing substrate fructose as well as prostaglandins and coagulating substrates. A recognized function of the seminal plasma is its buffering effect on the acidic vaginal environment. The coagulum formed by the ejaculated semen liquefies within 20 to 30 minutes as a result of prostatic proteolytic enzymes. The prostate also adds zinc, phospholipids, spermine, and phosphatase to the seminal fluid. The first portion of the ejaculate characteristically contains most of the spermatozoa and most of the prostatic secretions, while the second portion is composed primarily of seminal vesicle secretions and fewer spermatozoa.

Fertilization

Fertilization normally takes place within the uterine tubes after ovulation has occurred. During the menstrual mid cycle, the cervical mucus changes to become more abundant, thinner and more watery.

These changes serve to facilitate entry of the sperm into the uterus and to protect the sperm from the highly acidic vaginal secretions. Physiologic changes in the spermatozoa known as capacitation occur within the female reproductive tract in order for fertilization to occur. As the sperm cell interacts with the egg, there is initiation of new flagellar movement called hyperactive motility and morphologic changes in the sperm that result in the release of lytic enzymes and exposure of parts of the sperm’s structure known as the acrosome reaction. As a result of these changes, the fertilizing sperm cell is able to reach the oocyte, traverse it’s various layers, and become incorporated into the ooplasm of the egg.

Clinical Findings

History

The cornerstone of the evaluation of infertile man is a careful history and physical examination. Specific childhood illnesses should be sought including cryptographies, post pubertal mumps orchitis and testicular trauma or torsion. Precocious puberty may indicate the presence of an adrenal-genital syndrome, whereas delayed puberty may indicate Klinefelter’s syndrome or idiopathic hypogonadism. Prenatal exposure to diethylstilbesterol should be ascertained because this may cause an increased incidence of epididymal cysts or a slightly increased frequency of cryptorchidism. A detailed history of exposure to occupational and environmental toxins, excessive heat, or radiation should be elicited. Cancer chemotherapy has a dose-dependent and potentially devastating effect on the testicular germinal epithelium. The drug history should be reviewed for anabolic steroids, cimetidine, and spironolactone which can effect the reproductive cycle. Medications like sulfasalazine and nitrofurantoin may effect sperm motility. Illicit drugs and excessive alcohol consumption are associated with a decrease in sperm count and hormonal abnormalities. Previous medical and surgical diseases and their treatment may occasional compromise reproductive function. Men with unilateral undescended testes will have overall semen quality of considerably less than normal. Previous surgical procedures such as bladder neck operations or retroperitoneal lymph node dissection for testicular cancer may cause retrograde ejaculation or absent emission. Diabetic neuropathy may result in either retrograde ejaculation or impotence.

Both the vas deferens and the testicular blood supply can easily be injured during hernia repair. In patients with cystic fibrosis, the vas deferens or epididymis and seminal vesicles are usually absent. Any generalized fever or illness can impair spermatogenesis. The ejaculate may be affected for three months after the event, as spermatogenesis takes about 74 days from initiation to the appearance of mature sperm. There is also a variable transport time in the ducts. Sometimes events that have occurred in the previous 3-6 months are extremely important. Sexual habits including frequency of intercourse, frequency of ejaculation, use of coital lubricants and the patient’s understanding of the ovulatory cycle should be discussed. Previous infertility evaluation and treatment and the reproductive history from previous marriages should be ascertained. A history of recurrent respiratory infections and infertility may be associated with the immotile cilia syndrome, in which the sperm count is normal but the spermatozoa are completely non-motile due to ultrastructural defects. Kartagener’s syndrome, which is a variant of immotile cilia syndrome, consists of chronic bronchiectasis, sinusitis, situs inversus and immotile spermatozoa. In Young’s syndrome, also associated with pulmonary disease, the cilia ultrastructure is normal but the epididymis is obstructed due to inspissated material, and these patients present with azoospermia. Loss of libido associated with headaches, visual abnormalities and galactorrhea may suggest a pituitary tumor. Other medical problems that have been associated with infertility include thyroid disease, seizure disorders, and Liver disease. Interestingly it is not the seizure disorder itself that causes infertility but it is the typical treatment of it with Dilantin (phenytoin). Dilantin decreases FSH. Chronic systemic diseases such as renal disease and sickle cell disease are associated with abnormal reproductive hormonal parameters.

Physical Examination

During the physical examination, particular attention should be paid to discerning features of hypogonadism. Typically this would be viewed as poorly developed secondary sexual characteristics, eunuchoidal skeletal proportions i.e. arm span two inches greater than height, ratio of upper body segment (crown to pubis) to lower body segment (pubis to floor) less than 1, and the lack of normal male hair distribution ie. sparse axillary, pubic, facial, and body hair in conjunction with lack of temporal hair recession. One should be on the lookout also for infantile genitalia ie. small penis, testes, and prostate with under-developed scrotum. One may see a diminished muscular development and mass.

A careful examination of the testes is an essential part of the examination. Normal adult testes are on the average about 4.5 cm long and 2.5 cm wide with a mean volume of about 20 cc. A caliper or orchidometer may be used to measure testicular size. If the seminiferous tubules were damaged before puberty, the testes are small and firm. With postpubertal damage, they are usually small and soft.

Gynecomastia is a consistent feature of a feminizing state. Men with congenital hypogonadism may have associated midline defects such as anosmia, color blindness, cerebellar ataxia, hair lip, and cleft palate. Hepatomegaly may be associated with problems of hormonal metabolism. Proper neck examination may help rule out thyromegaly, a bruit or nodularity associated with disease. Neurologic exam should test the visual fields and reflexes.

Irregularities in the epididymis suggest a previous infection and possible obstruction. Examination may reveal a small prostate with androgen deficiency or slight tenderness (bogginess) in men with prostatic infection. Any penile abnormalities like hypospadias, abnormal curvature, phimosis, should be looked for. The scrotal contents should be carefully palpated with the patient in both the supine and standing positions. Many varicoceles are not visible and may only be discernible when the patient stands or performs the Valsalva maneuver. Varicoceles can often result in a smaller left testis, and a discrepancy in size between the two testes should arouse suspicion. Both vas deferens should be palpated, as 2% of infertile men have congenital absence of the vasa and seminal vesicles.

Hypothalamic Disease

Kallmann’s syndrome which is an isolated gonadotropin (LH and FSH) deficiency occurs in both a sporadic and familial form and although uncommon i.e. 1 in 10,000 men, it is second to Klinefelter’s syndrome as a cause of hypogonadism. The syndrome is often associated with anosmia, congenital deafness, hair lip, cleft palate, craniofacial asymmetry, renal abnormalities, color blindness.

The hypothalamic hormone GnRH appears to be absent. If exogenous GnRH is administered, both LH and FSH are released from the pituitary. Except for the gonadotropin deficiency, anterior pituitary function is intact. The syndrome appears to be inherited either as an autosomal recessive trait or an autosomal dominant trait with incomplete penetrance. The differential diagnosis should include delayed puberty. Kallmann’s syndrome distinguishing features though are testes less than 2 cm in diameter and positive family history with the presence of anosmia. “Fertile eunuch” are individuals with isolated LH deficiency. They have eunuchoid proportions with variable degrees of virilization and gynecomastia. They characteristically have large testes and semen containing a few sperm. Plasma FSH levels are normal but both the serum LH and testosterone concentrations are low normal. The cause appears to be a partial gonadotropin deficiency in which there is adequate LH to stimulate testosterone production with resultant spermatogenesis but insufficient testosterone to promote virilization. In isolated FSH deficiency which is rare, patient’s are normally virilized and have normal testicular size and baseline levels of LH and testosterone. Sperm counts range from O to a few sperm. Serum FSH levels are low and do not respond to GnRH stimulation. Congenital hypogonadotropic syndromes are associated with secondary hypogonadism and a multitude of other somatic findings. Prader-Willi syndrome is characterized by hypogonadism, hypomentia, hypotonia at birth and obesity. Laurence-Moon-Bardet-Biedel syndrome is an autosomal recessive trait characterized by mental retardation, retinitis pigmentosa, polydactyly and hypogonadism. These syndromes are felt to be due to a defect in hypothalamic deficiency of GnRH.

Pituitary Disease

Pituitary insufficiency may result from tumors, infarctions, iatrogenic causes like surgery and radiation or one of several infiltrative processes. If pituitary insufficiency occurs prior to puberty, growth retardation associated with adrenal and thyroid deficiency is the major clinical presentation. Hypogonadism that occurs in a sexually mature male usually has its origin in a pituitary tumor. Decreasing libido, impotence and infertility may occur years before symptoms of an expanding tumor i.e. such as headaches, visual abnormalities, or thyroid/adrenal hormone deficiency. Once an individual has passed through normal puberty, it takes a long time for secondary sexual characteristics to disappear unless adrenal insufficiency is present. The testes will eventually become small and soft. The diagnosis is made by low serum testosterone levels with low or low normal plasma gonadotropins concentrations. Depending on the degree of panhypopituitarism, plasma corticosteroids will be reduced with plasma TSH and growth hormone levels.

Hyperprolactinemia can cause both reproductive and sexual dysfunction. Prolactin-secreting tumors of the pituitary gland whether from a microadenoma (less than 10 mm) or a macroadenoma, can result in loss of libido, impotence, galactorrhea, gynecomastia and alter spermatogenesis. Patients with a macroadenoma usually first present with visual field abnormalities and headaches. They should undergo CT or MRI scanning of the pituitary and laboratory testing of anterior pituitary, thyroid and renal function. These patients have low serum testosterone levels but basal serum levels of LH and FSH are either low or low normal and reflect an inadequate pituitary response to depressed testosterone.

Approximately 80% of men with hemochromatosis have testicular dysfunction. Their hypogonadism may be secondary to iron deposition in the liver or may be primarily testicular as a result of iron deposition in the testes. Iron deposits have also been found in the pituitary, implicating this gland as the major site of abnormality.

With regard to the role of exogenous hormones, adrenocortical tumors, Sertoli cell tumors, interstitial cell tumors of the testes may all at times be estrogen-producing. Hepatic cirrhosis is associated with increased endogenous estrogens. Estrogens act primarily by suppressing pituitary gonadotropin secretion, resulting in secondary testicular failure. Androgens can also suppress pituitary gonadotropin secretion thereby leading to secondary testicular failure. The current use of anabolic steroids by certain athletes may result in temporary sterility. Endogenous androgen excess may be due to an androgen-producing adrenocortical tumor or testicular tumor but more likely to congenital adrenal hyperplasia. As a consequence of this disease, the production of androgenic steroids by the adrenal cortex is increased, resulting in premature development of secondary sexual characteristics and abnormal phallic enlargement. The testes failed to mature because of gonadotropin inhibition and are characteristically small. In the absence of precocious puberty, the diagnosis is extremely difficult since excessive virilization is difficult to detect in an otherwise normally sexually mature man. Careful laboratory evaluation is essential. Infertility caused by documented congenital adrenal hyperplasia is treatable with corticosteroids. Physicians have used corticosteroids in individuals with idiopathic infertility, but unless these abnormalities can be documented, steroid therapy has no place.

Sometimes glucocorticoid excess (prednisone usage) is exogenous in the therapy of ulcerative colitis, asthma, or rheumatoid arthritis. The result is decreased spermatogenesis. The elevated plasma cortisone levels depress LH secretion and can cause secondary testicular dysfunction. Correction of the glucocorticoid excess results in improvement in spermatogenesis. Hyper and hypothyroidism can alter spermatogenesis. Hyperthyroidism effects both pituitary and testicular function with alterations in the secretion of releasing hormones and increased conversion of androgens to estrogens.

Several somatic chromosomal abnormalities are associated with male infertility. In a study of 1,263 barren couples, it was found that the overall incidence of male chromosome abnormalities was 6.2%. In a subgroup in which the male partner’s sperm count was less than 10 million, the incidence rose to 11%. In azoospermic subjects, 21% had significant chromosomal abnormalities. Only in isolated cases however, has infertility been documented in association with a specific chromosomal abnormality i.e. D-D translocations, ring abnormalities, reciprocal translocation, and various other aberrations. Chromosomal studies though should be considered in men with severe oligospermia or azoospermia to look for autosomal and sex chromosomal abnormalities.

Klinefelter’s Syndrome is a genetic disorder due to the presence of an extra X chromosome in the male, the common karyotype being either 47,XXY which is the classic form or 46,XY/47,XXY the mosaic form. The incidence is about 1:500 males. Characteristically, these individuals have small, firm testes, delayed sexual maturation, azoospermia and gynecomastia. Because the features of hypogonadism are not evident until puberty, the diagnosis is delayed. The decrease in testicular mass is usually due to sclerosis and hyalinization of the seminiferous tubules. The testes characteristically have a length of less than 2 cm and 12 cc volume. LH and FSH levels are characteristically elevated. Testosterone levels can range from normal to low and decrease with age. Serum estradiol levels are often increased. The higher estrogen levels relative to testosterone cause the feminized appearance in gynecomastia. About 10% of these patients have chromosomal mosaicism. The mosaics have less severe features of Klinefelter’s Syndrome and may be fertile, as there may be a normal clone of the cells within the testes. Mild mental deficiency and restrictive pulmonary disease occur more frequently in these patients than in the general population. The infertility is reversible and later in life most of these men will require androgen replacement therapy for optimal virilization and normal sexual function.

XX Disorder or Sex Reversal Syndrome is a variant of Klinefelter’s Syndrome. The signs are similar except for the average height is less than normal, hypospadias is common and a decreased incidence of mental deficiency. These patients have a 46,XX chromosome complement. This paradox is explained by the fact that their cells express H-Y antigen and are presumed to have a Y chromosome somewhere in their genomes. The incidence of the XYY syndrome is the same as that of Klinefelter’s Syndrome but its phenotypic expression is more variable. Semen from these subjects may vary from azoospermic to normal. These patients are excessively tall and have had pustule acne. A percentage have anti-social behavior. Most have a normal LH and testosterone level with the FSH level dependent on the extent of germ cell damage. There is no treatment for their infertility.

Noonan’s Syndrome is the male counterpart of Turner’s Syndrome (X0), and these individuals typically have similar features i.e. short stature, web neck, low-head ears, cubitus valgus, ocular abnormalities and cardiovascular abnormalities. Most males with Noonan’s Syndrome have cryptorchidism and diminished spermatogenesis and are infertile. Those with diminished testicular function will have elevated serum FSH and LH levels. They demonstrate on chromosomal analysis a sex chromosome abnormality such as X0/XY mosaicism. There is no treatment for their infertility.

Patients with myotonic dystrophy suffer from delayed muscle relaxation after initial contraction. The major clinical features also include lenticular opacities, frontal baldness and testicular atrophy. Inheritance is autosomal dominant and the expression is variable though 80% will develop testicular atrophy. Pubertal development is usually normal and testicular damage occurs later in adult life. Leydig cell function remains normal and there is no gynecomastia.

Bilateral anorchia or vanishing testes syndrome is an extremely rare disorder effecting about 1 in 20,000 males. Patients will present at birth with non-palpable testes and sexual immaturity later in life because of the absence of testicular androgens. The karyotype is normal, but LH and FSH levels are elevated and testosterone is extremely low. In utero the testes may have been lost due to torsion, trauma, vascular injury or infection. However, functioning testicular tissue must have been present at least for the first trimester of fetal life in order for the male reproductive ducts and for the external genitalia to differentiate along male lines. Testosterone does not increase in response to HCG stimulation. These patients have eunuchoid proportions but no gynecomastia. Therapy can only be directed at the testosterone deficiency.

Sertoli-cell-only syndrome or germinal cell aphasia may have several causes including congenital absence of the germ cells, genetic defects, or androgen resistance. Upon testicular biopsy there will be complete absence of germinal elements. Clinical findings include azoospermia in association with normal virilization, testes of normal consistency but slightly smaller in size, and no gynecomastia. Testosterone and LH levels are normal but FSH levels are usually elevated. Sometimes in patients who have had other testicular disorders like mumps, cryptorchidism or radiation/toxin damage, the seminiferous tubules may also contain only Sertoli cells, but in these men the testes are small and the histologic pattern is not as uniform. These patients are more likely to have severe sclerosis and hyalinization as prominent features as well. There is no treatment for their infertility.

Gonadotoxins like drugs and radiation can effect the germinal epithelium because it is a rapidly dividing tissue and susceptible to interference of cell division. Cancer chemotherapy has a dose-dependent effect on testicular germinal epithelium. The germinal epithelium appears to be more resistant to toxic drugs before puberty than in adulthood. The alkylating agents like chiromancies, cyclophosphamide and nitrogen mustard are particular toxic to the testes. In some patients, cryopreservation of semen can be performed before cancer chemotherapy is begun. Cyproterone, ketoconazole, spirolactone and alcohol all interfere with testosterone synthesis. Cimetidine is a testosterone antagonist, blocking peripheral testosterone action. These men will often present with gynecomastia and have decreased sperm counts.

Recreational drugs like marijuana, heroin, and methadone are associated with lower serum testosterone levels without a concomitant elevation in LH levels. This suggests a central abnormality as well as a testicular defect. Certain pesticides like dibromochloropropane have been found to impair testicular function in men. Germ cells are particularly sensitive to radiation while the Leydig cells are relatively resistant. At exposures below 600 rads, germ cell damage is reversible. Above this level of exposure though permanent damage is likely. Recovered spermatogenesis may take up to 2-3 years even in men who receive low doses of radiation. Elevated FSH levels reflect the impaired spermatogenesis, with return to normal once the testes recover.

About 15-25% of adult men who contract mumps can develop orchitis which is more commonly unilateral though bilateral involvement occurs in about 10% of affected men. Testicular atrophy can develop within 1 to 6 months or may take years. Fewer than one-third of men with bilateral orchitis recover normal semen parameters.

The exposed position of the testicles make them susceptible to trauma and subsequent atrophy. Iatrogenic injury may occur during inguinal surgery and interfere with testicular blood supply or damage the vas deferens.

Systemic diseases like renal failure resulting in uremia in males is associated with decreased libido, impotence and altered spermatogenesis and gynecomastia. LH and FSH levels are elevated and testosterone levels are decreased. The cause of hypogonadism in uremia is probably multifactorial. It has been found that serum prolactin levels are elevated in one-fourth of the patients. An excess in estrogen may be contributory. Anti-hypertensive drugs and uremic neuropathy may also play a role in uremic impotence and hypogonadism. After successful renal transplantation, uremic hypogonadism improves. A large percentage of males with cirrhosis of the liver have testicular atrophy, impotence and gynecomastia. Testosterone levels are decreased. Estradiol is increased as a result of decreased hepatic extraction of androgens with increased conversion to estrogen peripherally. LH and FSH levels are only moderately elevated relative to the low serum testosterone levels. Ethanol also acutely reduces testosterone levels by inhibiting testicular testosterone synthesis. Many men with sickle cell disease have evidence of hypogonadism. Even though LH and FSH levels may be variable, testosterone levels are low. Hypogonadism of sickle cell disease is likely secondary to a mixture of testicular and pituitary-hypothalamic causes.

Rare heredity disorders due to enzymatic defects can result in defective testosterone synthesis and are associated with an adequate virilization that is evident at birth as ambiguous genitalia. Several forms of androgen resistance result in under masculinization and infertility in males with otherwise normally developed external genitalia. Diagnosis is made by the finding of abnormal androgen receptors in a culture of genital skin fiberblasts. Characteristically, there is an elevation testosterone and LH levels. Proof of this is costly and there is no treatment for their infertility.

Cryptorchidism is a common developmental defect incidence of 0.8% in adult males. The undescended testes become morphologically abnormal after age 2. Though in spite of prophylactic orchidopexy, unilateral cryptorchid patients have reduced fertility potential. It appears that in the cryptorchid individual, there is dysgenesis of both the normally and abnormally descended testis. Semen quality is particularly poor in patients with bilateral undescended testicles. Even though baseline serum FSH, LH and testosterone levels may be normal, there is a super normal response of both LH and FSH to generate stimulation which reflects compromised testicular function.

A scrotal varicocele is the most common causative finding in infertile men. It results from backflow of blood secondary to incompetent or absent valves in the spermatic veins. This valvular deficiency combined with the long vertical course of the internal spermatic vein on the left side, leads to the formation of most varicoceles on the left side (90%). Varicoceles are not as commonly seen on the right side because of the oblique course of the right internal spermatic vein from the vena cava. A unilateral right-sided varicocele suggests venous thrombosis/tumor or situs inversus. Newer diagnostic tests have shown the incidence of bilateral varicoceles to be greater than 40%. The incidence of varicoceles in the adult male population is approximately 20% and in the infertile population approximately 40%. 50% of men with varicoceles will have impaired semen quality, but many men varicoceles are fertile. To explain the abnormalities in spermatogenesis with varicocele, the following theories have been proposed:

Elevation of testicular temperature due to venous stasis

Retrograde flow of toxic metabolites from the adrenal or kidney

Blood stagnation with germinal epithelial hypoxia; and

Alterations in the hypothalamic-pituitary-gonadal axis.

Recent experimental evidence has demonstrated bilateral increase in both testicular blood flow and temperature with altered spermatogenesis. Unfortunately, at least 25-40% of infertile men have idiopathic infertility for which no cause can be identified. More known causes will be discovered hopefully as knowledge of male reproductive physiology expands.

Post- Testicular Causes Of Infertility

Disorders of sperm transport

Congenital disorders

Acquired disorders

Functional disorders

Disorders of sperm motility or function

Congenital defects of the sperm tail

Maturation defects

Immunologic disorders

Infection

Sexual dysfunction

Disorders Of Sperm Transport

Congenital disorders of sperm transport are rarely due to absence or atresia of portions of the male ductal system. Males with cystic fibrosis have a high incidence of congenital hypoplasia or absence of the major portion of the epididymis, vas deferens, and seminal vesicles. Absence of the seminal vesicles is always associated with azoospermia, semen that does not coagulate at ejaculation, and absence of fructose. In Young’s Syndrome which is associated with pulmonary disease, the ultrastructure of the cilia is normal but the epididymis is obstructed due to inspissated material leaving these patients azoospermic.

Acquired disorders of sperm transport are usually due to bacterial infections which may acutely or chronically involve the epididymis with subsequent scarring and obstruction. Apart from vasectomy, the vas may accidentally be ligated during hernia repair, orchiopexy, and even during varicocelectomy

Functional obstruction of sperm transport results from neuropathic insults like injuries to the sympathetic nerves during retroperitoneal lymph node dissection or pelvic surgery. This may cause lack of peristalsis of the vas deferens with resultant lack of emission and/or failure of the bladder neck to close at the time of ejaculation leading to retrograde ejaculation. Diabetic males with autonomic neuropathy frequently present with both erectile dysfunction and/or retrograde ejaculation. Spinal cord injury can result in paraplegia or quadriplegic with resultant erectile dysfunction and lack of emission and ejaculation. There are many medications such as tranquilizers, antidepressants, and antihypertensives that may interfere with the sympathetic nervous system as well.

Disorders of Sperm Motility or Function

Disorders of sperm motility and function exist secondary to problems that include congenital defects of the sperm tail, maturation defects and immunologic defects. Immotile cilia syndrome is a group of disorders characterized by immotility or poor motility of spermatozoa tie. Kartagenerss Syndrome). In these disorders, testicular biopsy is normal and the sperm count adequate but sperm motility is either markedly reduced or absent. The defective structural abnormality leading to impairment of both the cilia and spermatozoa is seen only with the electron microscope. The defects known to cause immotile cilia syndrome include absent dynein arms, short or absent spokes with no central sheath and missing central microtubules. Motility problems may also be associated with a deficiency of the protein carboxylmethylase in the tail of the sperm. Normal sperm counts with poor motility following vasectomy reversal may be a result of epididymal dysfunction. Chronic intratubular pressure following vasectomy may have a deleterious effect on the epididymis such that spermatozoa may not gain their usual maturation and capacity for motility. Breakdown of the blood-testes barrier by infection, trauma or operation allows sensitization of the spermatozoa antigens. Sperm antibodies may be a relative cause of infertility in about 3-7% of infertile males. Immunity does not appear to be an all-or-none phenomenon but may contribute to reduced fertility potential.

Infections. High concentrations of gram-negative bacteria like E-coli in the semen can impair sperm motility. Sexually transmitted organisms such as chlamydia trichomatous, mycoplasma hominis and ureaplasma urealyticulum have rarely been implicated in reproductive failure. In both animals and humans, there is no convincing evidence to support the use of routine cultures or empiric therapy in asymptomatic infertile males.

Sexual dysfunction has been reported in up to 20% of infertile males. Decreased sexual drive, erectile dysfunction, premature ejaculation and failure of intromission are all potentially correctable causes of reproductive failure. Decreasing libido and erectile dysfunction may reflect low serum testosterone levels with an organic cause. Performance anxiety is also often reported and often abated with reassurance.

Diagnostic Testing

Semen Analysis

Although semen analysis is not a test of fertility, a carefully performed semen analysis is a highly predictive indicator of the functional status of the male reproductive hormonal cycle, spermatogenesis and the patency of the reproductive tract. The initiation of a pregnancy is the only true measure of fertility and is a couple-related phenomenon. One must keep in mind that normal values have been difficult to determine for fertile men in their reproductive years. Clinical studies of infertile patients have established “limits of adequacy” below which the chance of initiating a pregnancy becomes more difficult. These parameters are not absolute because some fertile men may have values below these “limits of adequacy”. Conversely, infertile men may have normal semen parameters by standard analysis techniques because standard evaluation does not assess the functional integrity of the sperm. The World Health Organization Laboratory Manual for Examination of Human Semen and Semen-Cervical Mucous Interactions is highly recommended for technical details.

Most specialists collect at least three specimens in which the seminal parameters are within 20% of each other before establishing a baseline for semen quality. The semen specimen is best obtained by masturbation after a two to three day period of abstinence. The specimen should be assessed within 1-2 hours of collection. Samples obtained by coitus interruptus or from silastic condoms devoid of spermatocidal agents are less desirable but satisfactory. Therefore, collection at the site of analysis is ideal. Besides laboratory error, there are variations in sperm density, motility and morphology among multiple samples from a given man. Abstinence intervals give s large source of variability. With each day of abstinence (up to one week) semen volume increases by 0.4 cc, sperm concentration by 10-15 million per cc, and total sperm count by 50-90 million. Sperm motility and morphology appear to be unaffected by 5-7 days of abstinence, but longer periods lead to impaired motility. Interpretation of semen analysis must take into consideration the variations between samples that exist in individuals. The minimum number of specimens to define good or poor quality of semen is three samples over a 6-8 week interval with a consistent period of abstinence of 2-3 days. In a longitudinal analysis of semen from both fertile and infertile men, it was found that 97% of men with initial good sperm concentration would continue to show good density after as many as 3-6 specimens. Those rated poor at first also remained poor in future visits. For those rated equivocal, first visit was of little value and at least three visits were needed to obtain stability.

Semen volume must be taken into consideration assessing total sperm production by the testes. Semen volume per se, however, effects fertility only when it falls below 1.5 cc due to the inadequate buffering of vaginal acidity or when the volume is greater than 5 cc. Low volumes may be associated with incomplete collection, retrograde ejaculation, ejaculatory duct obstruction, or androgen deficiency. For most clinicians, a sperm concentration of less than 20 million per cc is the lower limit of normal. Sperm motility is the single most important measure of semen quality and can be a compensatory factor in men with low sperm counts.

Sperm motility is usually rated in two ways: the number of motile sperm as a percentage of the total, and the quality of forward progressive sperm movement i.e., how fast and how straight the sperm swims. The degree of forward progression is a classification based on the pattern displayed by the majority of motile sperm. It ranges from zero (no movement) to 4 (excellent forward progression). Typically, you want to see at least 50% of the sperm with good forward progression. Microscopic evaluation of the liquefied semen may reveal agglutination (clumping) of sperm. Agglutination may be head-to-head, head-to-tail, or tail-to-tail and may suggest an inflammatory or immunologic process. Sperm morphology is subject to great variation and it is unusual to see specimens that contain more than 80% normal sperm heads.

Morphology is assessed on stained seminal smears and is scored; after viewing at least 100 cells. Typically, you like to see at least 30% of the sperm having normal oval heads, mid piece and tail. No longer is it felt that increased numbers of tapered, amorphous and immature cells (stress pattern) are pathonomic of varicoceles, but rather represent altered testicular function. Semen from normal men coagulates and then over 20-30 plus minutes liquefies. Delayed liquefaction of semen greater than 60 minutes may indicate disorders of accessory gland function. Diagnosis of the liquefaction problem should be made if there is absence of sperm in the post coital test. If sperm are capable of reaching the cervical mucus, problems of semen liquefaction are not clinically relevant. Increased semen viscosity, which is unrelated to the coagulation-liquefaction phenomenon, signifies a disorder of accessory gland function and may effect the accuracy of assessment of both sperm density and motility. It is only clinically relevant when there are very few sperm in the post coital test.

The presence of white blood cells in semen should be noted. It is difficult to differentiate between white blood cells and immature spermatozoa on routine analysis, because both may appear as round cells in the semen. Peroxidase stain and, more recently monoclonal antibodies have been utilized to aid in this differentiation. Excessive white cells ( > 1 million/cc) may indicate an infection that may contribute to subfertility. If no spermatozoa are observed, a qualitative test for fructose should be performed. A low ejaculate volume and lack of fructose, along with failure of the semen to coagulate, suggest congenital absence of the vas deferens and seminal vesicles or obstruction of the ejaculatory ducts. Fructose is androgen-dependent and is produced in the seminal vesicles.

Computer-assisted semen analysis (CASA) systems couple video technology and sophisticated microcomputers for automatic image digitalization and processing. This technology was developed for more objective measurements of seminal parameters over the subjective measures of standard semen analysis. CASA permits the measurement of additional motility parameters such as curvalinear velocity, straight-line velocity, linearity, and flagellar beat frequency. Under certain circumstances, CASA has been found to be less accurate than the standard semen analysis and the biological and clinical relevance of some of these new parameters has yet to be validated.

Hormone Evaluation

Most cases of male infertility are non-endocrine in origin. Routine evaluation of hormonal parameters is not warranted unless sperm density is extremely low or there is clinical suspicion of an endocrinopathy. The incidence of primary endocrine defects in infertile men is less than 3%. Such defects are rare in men with a sperm concentration of greater than 5 million per cc. When an endocrinopathy is discovered, however, specific hormonal therapy is often successful. Because of the episodic nature of LH secretion and its short half life, a single LH determination has an accuracy of plus or minus 50%. Similarly, testosterone is secreted episodically in response to LH pulses and has a diurnal pattern with an early morning peak. Serum FSH has a longer half life, and these fluctuations are less obvious. Therefore, I usually just check an FSH and testosterone level. A low testosterone level is one of the best indicators of hypogonadism of hypothalamic or pituitary origin.

Low LH and FSH values concurrent with low testosterone levels indicate hypogonadotropic hypogonadism. Elevated FSH and LH values help to distinguish primary testicular failure (hypergonadotropic hypogonadism) from secondary testicular failure (hypogonadotropic hypogonadism). Most patients with primary hypogonadism have severe, irreversible testicular defects. On the other hand, secondary hypogonadism has a hypothalamic or pituitary origin and infertility may be correctable. Elevated FSH levels are usually a reliable indicator of germinal epithelial damage and are usually associated with azoospermia or severe oligospermia, depicting significant and usually irreversible germ cell damage. In azoospermic and severely oligospermic patients with normal FSH levels, primary spermatogenic defects cannot be distinguished from obstructive lesions by hormonal investigation alone. Therefore, scrotal exploration and testicular biopsy should be considered. An elevated FSH level associated with small, atrophic testes implies irreversible infertility and a biopsy is not warranted.

The diagnostic value of prolactin measurement is extremely low in men with semen abnormalities unless these are associated with decreased libido, erectile dysfunction, and evidence of hypogonadism. Prolactin measurement is warranted in patients with low serum testosterone levels without an associated increase in serum LH levels.

Individuals with gynecomastia, obesity, history of alcohol abuse, or suspected androgen resistance should have a serum estradiol level. In men with a history of precocious puberty, one should consider congenital adrenal hyperplasia. In the common variant (21-hydroxylase deficiency), serum levels of 17-hydroxyprogesterone are elevated. In 11-hydroxylase deficiency, serum 11-Deoxycortisol levels are elevated.

In patients with hypogonadotropic hypogonadism, the pituitary hormones other than LH and FSH should also be assessed like adrenal corticotropic hormone (ACTH), thyroid stimulating hormone (TSH), and growth hormone (GH). Thyroid dysfunction is such a rare cause of infertility that routine screening for thyroid abnormality should be discouraged.

Chromosomal Studies

Only in isolated cases has infertility been documented in association with a specific chromosomal abnormality. Subtle genetic studies can be considered in men with severe oligospermia and azoospermia to look for both autosomal and sex chromosomal abnormalities. The diagnostic yield is greatest in men with small testes, azoospermia, and elevated FSH levels.

Immunologic Studies

Antisperm antibodies, although not an absolute cause of infertility, appear to be capable of reducing the likelihood of pregnancy. The concentration of antisperm antibodies in the semen influence the degree of impairment. Antisperm antibodies do not lyse or immobilize sperm. They have not generally been found to be associated with decreased density or motility, but they do appear to interfere with sperm function by simply attaching to the plasma membrane of the spermatozoa. Sperm agglutination may be caused by antisperm antibody attachment. Infections may lead to agglutination of sperm as well though. Whenever agglutination is observed, the possibility of infection should be evaluated with appropriate semen cultures. Antisperm antibodies should be suspected in couples with repeated abnormal post coital tests. Antisperm antibodies appear to interfere with normal penetration and transit of sperm through normal cervical mucus.

Antisperm antibodies also should be suspected in subfertile men with a history compatible with disruption of the integrity of the genital tract, and when sperm agglutination or reduced motility is observed on semen analysis. Immunological factors may also play a role in the pathogenesis of 10-20% cases of “unexplained infertility”. Antisperm antibodies can be found either in the circulation or in the seminal plasma or directly on the sperm surface. Studies have shown a discordance between the results of sperm antibody tests in matching serum and sperm samples. The presence of humoral antibodies directed against sperm is not relevant to fertility unless these circulating antibodies are also present within the reproductive tract. Therefore, the convenience of assaying blood for antisperm antibodies is outweighed by the lack of clinical relevance of these measurements in comparison with assays that identify the immunoglobulins directly on the sperm surface. It appears therefore that tests capable of detecting antisperm antibodies on living sperm are the most direct way to determine whether a significant autoimmunity to sperm exists. The immunobead binding test (IBT) is one of the most informative and specific of all assays currently available to detect antisperm antibodies bound to the surface of sperm.

Special And Sperm Function Tests

Sperm-Cervical Mucus Interaction

For fertilization to take place in-vivo, the sperm must be able to get past the cervical mucus. The post coital test assesses the ability of sperm to penetrate and progress through cervical mucus. Cervical mucus is examined 2-8 hours after intercourse at the time of expected ovulation. The presence of greater than 10-20 motile sperm per high power field is generally accepted as a normal post coital test. Post coital testing is a bio-assay that provides information concerning sexual function, motility of the sperm, and the sperm-mucus interaction. A positive result implies normal semen and mucus. A poor result in an individual with normal semen parameters implies either cervical abnormality or the presence of sperm antibodies. Sperm-mucus interaction may also be assessed in-vitro. This allows for some degree of standardization. Human or bovine ovulatory mucus is placed in a capillary tube. Sperm penetration into the mucus is measured over a fixed period of time. These in-vitro techniques enable one to compare patient specimens with fertile sperm and control some of the variables associated with standard post coital testing.

Sperm Penetration Assays

Penetration of an oocyte requires sperm capacitation, acrosome reaction, fusion and incorporation into the oocyte. Cross-species fertilization is normally prevented by the zona pellucida. Hamster eggs stripped of the zona pellucida can be penetrated by human sperm. This in-vitro functional test measures the penetration ability of the sperm. The end point of this assay is penetration of the ovum and decondensation of sperm heads. The percentage of oocytes penetrated and the number of sperm penetrating each oocyte are measured. Sperm that are capable of multiple penetrations per oocyte appear to have greater fertilizing potential than sperm that do not penetrate. The results of the sperm penetration assay (SPA) have primarily been used to predict the results of assisted reproductive techniques, in particular, in-vitro fertilization. Men with sperm of low SPA score are less likely to achieve a spontaneous pregnancy than those with a high SPA score. It must be emphasized that the abnormal penetration does not indicate that fertilization cannot occur, nor does good penetration assure fertilization. Although variations still exist between laboratories, there appears to be general agreement that less than 10% penetration is evidence of sperm dysfunction and male infertility. Indications for SPA include unexplained infertility, and its use is also recommended prior to expensive assisted reproductive techniques. Although the SPA is a reliable indicator of the fertilizing capacity of human spermatozoa, it does not predict the ability of sperm to bind to and penetrate zona pellucida or the sperm’s motility and progression in the female reproductive tract.

For as SPA with zona free hamster eggs can demonstrate completion of the human sperm acrosome reaction and sperm oocyte plasma membrane fusion, only tests with human zona pellucida can assess the capability of human sperm to bind to the human oocyte. The hemizona assay uses zona pellucida from non-living human oocytes that have been microsurgically bisected. Sperm are allowed to interact and bind with the hemizona. The patient’s sperm and fertile sperm are compared utilizing the identical halves of hemizona. The results are expressed as the hemizona index, i.e. bound sperm by the subfertile man divided by bound sperm from the fertile donor multiplied by 100. This assay requires significant expertise in micromanipulation. The hemizona assay is not indicated in the routine evaluation of the subfertile man.

Acrosome Evaluation

The acrosome reaction is necessary for fertilization to take place. Evaluating the ability of sperm to undergo the acrosome reaction may provide an additional assessment of sperm function.

It is possible to determine the acrosomal status of sperm by utilizing electron microscopy, staining, immunofluorescent techniques and monoclonal antibodies. It is also possible to induce an acrosome reaction with ionophores and human zona pellucida. These techniques are labor-intensive and the ability of the acrosomal status to predict fertility must be confirmed.

Hypo-Osmotic Swelling

It has been found that when sperm from normal fertile men are exposed to a known solution of fructose and sodium citrate, 33-80% of the spermatozoa will exhibit tail swelling. Sperm that are not viable or sperm with non-functioning membranes do not swell. This appears to be explained by the ability of the normal cell membrane to maintain an osmotic gradient. Attempts have been made to correlate this finding with the fertilization potential for semen samples. Samples with greater than 62% swelling are able to fertilize ova, whereas less than 60% swelling is observed in samples of infertile semen. This test has not been widely embraced and is currently a research tool.

Bacteriologic Investigation

If urinalysis is abnormal or bacterial prostatitis is implicated by either the history or physical examination, appropriate cultures are indicated. The common sexually transmitted organisms such as chlamydia trachomatis, mycoplasma hominus and ureaplasma urealyticulum have been implicated in reproductive failure in animals and humans.

On the basis of this supposition, physicians have instituted antibiotic therapy without obtaining evidence of infection in the hope of improving fertility. We currently could find no evidence for the role of current asymptomatic infection due to the above organisms in male infertility. Without evidence of inflammation, there is no indication for routine culture or antibiotic treatment of infertile men.

IVF – In Vitro Fertilization Tips

How In Vitro Fertilization is Done

When a woman, or couple, and the Fertility Specialist determine that in vitro fertilization is the treatment of choice, there are several steps that must be taken to promote the greatest chance of success.

The primary steps in in vitro fertilization include:

Counseling – you will discuss the IVF process, risks and benefits, and outcome goals. Treatment consents will be signed, which may include consents for IVF and embryo transfer, micro-insemination, cryopreservation of resultant embryos and psychological treatment/evaluation.

Testing – including ultrasound and hormone levels to establish baseline uterine and hormonal status, for the syncing of your IVF cycle

Fertility drugs – hormones will be provided to the woman, to stimulate egg production, including superovulation, where the ovaries produce more than one egg during a cycle. A greater number of eggs increases the chances for a successful IVF. Drugs will be added at different times during the IVF cycle, to prepare the uterus for implantation, promote egg and follicle development, and aid in egg retrieval or harvesting.

Egg Retrieval – eat or drink nothing 8 hours prior to your retrieval. Ultrasound is used to guide the needle as it enters the ovary for harvest, through the vaginal wall.

Fertilization – concentrated sperm is introduced to your eggs, in a petri dish or test tube

Transfer – with the use of a speculum, the procedure is similar to a Pap smear. An ultrasound guides placement of the embryos inside the uteris.

The steps related to IVF are fairly consistent, regardless of the Fertility Clinic that you use, due to the sequential nature of the human body in terms of fertility. Following the guidelines and instructions of your Fertility Specialist, will help to promote positive outcomes following IVF.

Ethical and Moral Issues Related to In Vitro Fertilization

The use of assistive reproductive technologies is more than just a question of medical treatment and conception.

There are also ethical and moral dilemmas that can be a part of this process, which can include, but are not limited to:

Fate of any stored embryos should a couple divorce – is the embryo property or a person. Who can claim the embryo or determine if it is to be destroyed or kept in frozen stasis?

Rights of the sperm or egg donor – some States laws include that donors have no parental rights, however this is not as clearly delineated in other States.

Destruction of residual embryos – are we, in fact, murdering children? Some religious beliefs feel that we are taking the life of a child, rather than a potential being.

Selective reduction in the event of multiple successful implants – selective abortion of a fetus or more than one fetus, to promote a more successful outcome for the remaining fetuses, is viewed the same as the destruction of residual embryos. Some believe that a child begins at conception rather than at birth.

Religious morality regarding the use of assistive reproductive technologies (ART)- the Catholic tenets specifically restrict the use of ART such as IVF. The Donum Vitae states that intrusion of someone other than a man and his spouse in the making of a child is immoral, which rules out donor sperm and eggs, and fertility treatments to promote conception.

Beyond the physical aspects of the in vitro fertilization, there are also the social and moral aspects that some feel must be considered when making the determination to create a child using a test tube.

Role of In Vitro Fertilization in Fertility Treatment

There are many causes of infertility, including hormonal problems, structural or mechanical issues and medical conditions. There are also many different treatments available, to address the specific causes of infertility, such as hormone treatments or surgical correction of structural anomalies.

In vitro fertilization – IVF – is one type of infertility treatment, however it is not a first line treatment. Your Fertility Specialist will try other less invasive and less expensive options before choosing IVF, since many causes of infertility can be overcome with other treatment options.

IVF is best used for those situations in which a woman is trying to conceive and intrauterine insemination is not possible or effective, or in which donation of eggs or sperm is necessary to complete the process due to either male or female fertility problems within a couple.

Risks and Complications of In Vitro Fertilization

As with any medical treatment or procedure, there are potential risks and complications.

This is true for in vitro fertilization, which has its own special risks that can include:

Ovarian Hyper-stimulation Syndrome – a reaction related to excessive elevation of estrogen levels and the hormone given to ripen the eggs for harvest, resulting in: fluid in the abdominal cavity, blood clots in the large blood vessels, swelling of the ovaries, which have a risk of rupturing or twisting.

Egg Retrieval Risks – since anesthesia, general IV sedation and a needle are used for retrieval, anesthetic reaction, infection at the needle insertion site, bleeding, damage to adjacent internal organs and scarring are risks of the procedure.

Sperm Collection and Preparation Effects – this is a stressful time for the man, who may have erectile difficulties or even changes in sperm count in response to stress.

Embryo Transfer Side Effects – after embryo implantation, the woman may experience vaginal dryness, PMS symptoms such as bloating and tender breasts, depression or mood changes, which can be a result of the hormones administered to prepare the ovaries and uterus for the fertilization process.

Psychological Symptoms – infertility is stressful in itself. Add to this, the stresses related to chemicals, physical evaluations and treatments, and anxiety or depression may result, in addition to sleep abnormalities, tensions within the relationship and stress-related illness.

Recognizing the potential risks and complications involved with IVF will help you better prepare for the process and the potential side effects.

Defining In Vitro Fertilization

The process of In Vitro Fertilization was initially brought to fame by the creation of the world’s first “test tube baby” – a breakthrough in assistive reproductive technology, also called ART, that has helped many people achieve pregnancy and childbirth, when other fertility treatment options proved ineffective.

The IVF was first pioneered by Embryologist, Dr. Edwards, and Gynecologist, Dr. Steptoe, in England in 1978, to help couples who were unable to have children, by natural conception, due to fertility problems that could not be overcome with traditional treatments.

The term “in vitro” means, “outside the living body,” and was initially referred to as in vitro fertilization – pre-embryonic transfer, or IVF-ET, to refer to the stage of cell development at the time of the implantation into the woman’s uterus.

Alternatives to In Vitro Fertilization

Since IVF is not the first line treatment for infertility, there are other available options. Some of these options include:

Hormonal therapy – sometimes it is a hormonal imbalance that is preventing conception, and correction of this imbalance can result in successful pregnancy

Surgical intervention – if structural problems, such as blocked fallopian tubes or blockage of sperm ducts, are contributing to infertility, repair of these reproductive parts can successfully promote conception

Treatment of external causes – if acquired infection, radiation treatment for cancer or other externally generated cause of infertility is present, correction of these causes can aid in correcting infertility

Alleviation of medical conditions – cysts on the ovaries or testes, diabetes, pituitary tumor or other medical conditions can contribute to infertility and, when corrected, the result is a successful pregnancy and delivery

Counselling or therapy – if emotional factors are contributing to infertility, such as fear of failure, depression or anxiety resulting in erectile dysfunction or painful intercourse, counselling or other psychotherapy can help to relieve these symptoms, and promote sexual function and fertility

Other assistive reproductive technologies – intrauterine or intrafallopian insemination involve placement of sperm directly into the uterus or fallopian tubes during ovulation.

There are a multitude of causes of infertility and a corresponding number of treatment options, many of which are readily available, inexpensive and effective.

Fertility Drugs and IVF

In order for in vitro fertilization to be successful, assistance must be provided in the form of fertility drugs.

These drugs are designed to stimulate and emulate hormones which normally regulate reproductive activities, to control the reproductive cycle and promote success with IVF. The primary drugs used in IVF include

Progesterone is taken daily beginning two days after egg retrieval to support the embryo in the uterus until the placenta is able to make enough progesterone. This takes about 2 months.

Doxycycline is given to the male partner during the woman’s stimulation cycle to reduce bacteria that may be present in the sperm.

Medrol is a steroid hormone given daily, for up to four days, to assist pre-embryo implantation in the uterine wall, following embryo transfer.

Pregnyl, Profasi or Novarel is taken to help maturate the eggs and prepare them for retrieval. Gonal F, Bravelle, Follistim, Pergonal and Repronex are the most commonly used gonadotropins and they stimulate the egg follicle to ripen during inadequate follicular development.

What is ICSI?

ICSI is an acronym for in tracytoplasmic sperm injection – which is a long, fancy way of saying “inject sperm into the middle of the egg”. ICSI is a very effective method to get fertilization of eggs in the IVF lab after they have been retrieved from the female partner.

IVF with ICSI involves the use of specialized micromanipulation tools and equipment and inverted microscopes that enable embryologists to select and then pick up individual sperms in a tiny specially designed hollow ICSI needle. Then the needle is carefully advanced through the outer shell of the egg and egg membrane and the sperm is then injected into the inner part (cytoplasm) of the egg. This will usually result in normal fertilization in approximately 70-85% of eggs injected with viable sperm. First, the woman must be stimulated with medications and have an egg retrieval procedure so that we can obtain several eggs in order to attempt in vitro fertilization and ICSI.

Who should be treated with intracytoplasmic sperm injection?

There is no “standard of care” in this field of medicine regarding which cases should have the ICSI procedure and which should not. Some clinics use it only for severe male factor infertility, and some use it on every case. The large majority of IVF clinics are somewhere in the middle of these 2 extremes. Our thinking has changed over time – we are now doing more ICSI (as a percentage of total cases) than in the past. Certainly, as we learn more about ways that we can help couples conceive, our thinking in this area will continue to evolve. Having said that, we are currently recommending in vitro fertilization (IVF) with ICSI for:

All couples with severe male factor infertility that do not want donor sperm insemination

All couples having IVF who have had a previous cycle with no fertilization – or a low rate of fertilization (low percentage of mature eggs that are normally fertilized).

All couples having IVF who have a very low yield of eggs at the egg retrieval – our current cutoff is 5-6 (or less) eggs. In this scenario, ICSI is being used to try to get a higher percentage of eggs fertilized than with conventional insemination of the eggs (just mixing eggs and sperm together).

How is ICSI performed?

The mature egg is held with a specialized holding pipette.

A very delicate, sharp and hollow needle is used to immobilize and pick up a single sperm.

This needle is then carefully inserted through the zona (shell of egg) and in to the cytoplasm of the egg.

The sperm is injected in to the cytoplasm and the needle carefully removed.

The eggs are checked the next morning for evidence of normal fertilization.

Fertilization and pregnancy success rates with ICSI

Fertilization rates for ICSI: Most IVF programs see that about 70-85% of eggs injected using ICSI become fertilized. We call this the fertilization rate, which is different from the pregnancy rate.

Pregnancy success rates for in vitro fertilization procedures with ICSI have been shown in some studies to be higher than for IVF without ICSI. This is because in many of the cases needing ICSI the female is relatively young and fertile (good egg quantity and quality) as compared to some of the women having IVF for reasons other than male factor infertility. Another way to say this is – average egg quantity and quality is usually better in ICSI cases (male factor cases) because it is less likely that there is a problem with the eggs – as compared to cases with unexplained infertility in which there is more probability of a somewhat reduced egg quantity and quality (on the average, since some women in this group have egg related issues).

ICSI success rates vary according to the specifics of the individual case, the ICSI technique used, the skill of the individual performing the procedure, the overall quality of the laboratory, the quality of the eggs, and the embryo transfer skills of the infertility specialist physician performing the procedure.

Sometimes IVF with ICSI is done for “egg factor” cases – low ovarian reserve situations. This is when there is either a low number of eggs, or lower “quality” eggs (or often both). In such cases, ICSI fertilization and pregnancy success rates are somewhat lower (as a group) since the main determinant of IVF success is the quality of the transferred embryos – and the quality of the eggs is the most crucial factor determining the quality and viability of the resulting embryo.

In some cases, assisted hatching might be done on the embryos prior to transfer, in order to maximize chances for pregnancy.

The ICSI Procedure

During the ICSI procedure, the head of a single sperm is injected into the egg, eliminating the need of the sperm to penetrate the egg for fertilization.

Step 1: Ovulation Stimulation and Egg Retrieval

A full ICSI cycle includes a number of steps. First, the woman may be prescribed fertility drugs to help stimulate ovulation, control the egg ripening, and make it possible to collect multiple eggs. When it has been determined through ultrasound that the eggs are ready, they are retrieved in a minor surgical procedure in which a hollow needle is used to remove the eggs from the ovaries.

Step 2: Sperm Retrieval

For men with low sperm count or motility, sperm is obtained through normal ejaculation. For those with other fertility problems, surgical procedures such as microepididymal sperm aspiration (MESA), percutaneous epididymal sperm aspiration (PESA), or testicular sperm extraction (TESE) may be necessary to retrieve the sperm.

Step 3: Fertilization

Once the sperm and eggs have been retrieved, a single sperm is picked up with a very small needle which is inserted through the zona pellucida (the shell of the egg) and into its center (cytoplasm). The fertilization will be confirmed within about one to six days.

Step 4: Embryo Transfer

The resulting embryo or embryos are placed in the woman’s uterus in a procedure called embryo transfer. Multiple embryos, typically between two and four, may be placed in the uterus to increase the probability of pregnancy.

Are ICSI babies more likely to have birth defects?

Despite widespread use and acceptance, ICSI is still a relatively new procedure. Currently there are no reports of increased birth defects or congenital abnormalities in babies born through ICSI. Children born as the result of ICSI are very young and have not yet reached an age to reproduce.

ICSI bypasses the natural selection process at the egg surface that may prevent “undesirable” sperm from fertilizing the egg. This may permit the transfer of certain male infertility conditions that have a genetic basis. Where a genetic basis to male infertility is suspected or known, the couple can consult with a genetic counselor before choosing to use ICSI.

A cycle of ICSI and IVF costs $10,000 or more, depending on where you live and what extra options are involved, and it may take more than one cycle to achieve a pregnancy. ICSI costs about $1200 to $1500 as a stand alone procedure.

ICSI Risks

Most studies show that there is no increase in birth defects and other problems with babies born from an ART pregnancy than babies born by natural methods. Regardless, concern still exists about the quality of the sperm used in the ICSI procedure.

In natural conception, only the hardiest sperm are able to fertilize an egg, thereby weeding out lower-quality sperm. During the ICSI treatment, sperm is chosen and injected into the egg, allowing for the possibility that weaker sperm will be used. If severe male infertility is a factor, the concern is that the causes of the infertility may be passed on to children, along with other chromosomal abnormalities and genetic problems that are associated with infertility.

To determine the risk of passing these genetic problems to children, some specialists suggest that a couple undergo genetic screening before ART procedures such as ICSI.

What’s So Great About It?

Previous to ICSI, the only options to couples where the male partner had a low sperm count, a complete absence of sperm in his semen, a damaged or even absent vas deferens, an irreversible vasectomy or a host of other problems was to adopt, use a sperm donor or deal with the possibility of never having children. Understandably, many couples did not care for these limited options.

Using micromanipulation technology, ICSI allows fertility specialists to fertilize an egg using just one sperm. While it is preferred to use sperm from a semen sample, specialists can retrieve sperm from the testicles if it is necessary. Once sperm has been collected, the specialist will draw a single sperm into a needle and inject it directly into an egg that has been collected from the female partner through the usual retrieval methods. This process bypasses the conventional IVF methods of fertilization, thereby ensuring that fertilization has taken place. The fertilized eggs are then left to culture for a few days before being transferred back to the woman’s uterus. ICSI is always used alongside IVF.

Who is Suited to ICSI?

Couples that are infertile due to any of the following reasons may want to consider using ISCI with their IVF treatment.

Lack of any sperm in ejaculate due to CAVD, failed vasectomy reversal, failure to produce sperm, or an obstruction in the epididymus due to past inflammation

Retrograde ejaculation

Immunological factors

Additionally, men who have been diagnosed with testicular cancer may choose to freeze a semen sample before undergoing treatment as this can later be used in ICSI.

Success with ICSI

While the fertilization rates with ICSI remains pretty high at between 60% and 70% depending on the quality of sperm used, pregnancy rates remain about the same as they do with IVF. Approximately 20% to 25% of couples undergoing ICSI and IVF will have a live birth. However, one concern among many experts is how healthy this procedure is for the resulting children.

Because ICSI is used mainly in men with extremely poor sperm quality, the fact that it allows an egg to be fertilized with any sperm, rather than the strongest, has caused concern that congenital defects may be passed on at a greater rate. Additionally, it is a relatively new procedure and the long term effects in children conceived through ICSI have yet to be properly analyzed. However, so far no studies have shown that children conceived with ICSI do have any increase in congenital defects. If there is a known risk of genetic diseases or disorders in your family, though, you may want to consider using PGD.

Moreover, because ICSI is used alongside IVF, couples undergoing this treatment do have an increased risk of ectopic pregnancy as well as multiple births.

Predetermining The Sex of Your Child

The following methods are the current theories regarding gender selection while trying to conceive.

The Shettles Method

The Shettles, by Dr. Landrum Shettles and David Rorvik, authors of How To Choose the Sex of Your Baby, is the method most used and most effective. According to this method Y-chromosomes (for boys) move faster but don’t last as long as X-chromosomes (for girls), Dr Shettles says it makes sense to have sex as close as possible to ovulation if a boy is what you want. If you try to conceive two to four days before you ovulate, you’ll most likely have a girl.

The Whelan Method

Elizabeth Whelan, Sc.D., doesn’t agree with the Shettles method and suggests the opposite. Whelan says if you want a boy, have intercourse four to six days before your basal body temperature goes up.

If you want a girl, don’t make love until two to three days before ovulation.

The Ericsson Method

In 1975, Ronald J. Ericsson, Ph.D. began clinical studies to determine whether such enriched sperm samples would result in offspring of a desired gender. Today the Ericsson method is used in approximately half of the centers in the U.S.

Dr Ericsson devised methods by which X and Y sperm can be separated through filtering processes. This sperm sample is used for insemination when ovulation is anticipated. The enriched sperm sample is then available to fertilize the egg.

The Billings Method

A daily record of observations made at the vulva is essential for the Billings Ovulation Method. The recording is made in the evening of the most fertile characteristics noticed throughout the day. The first record, which is begun immediately, is usually of 2 – 4 weeks duration and is made without any genital contact so that the observations will not be confused by any secretions due to intercourse or contact. Your chart provides information for your husband as well, and it helps open the door for communication and decisions during these times.

A helpful question to an anxious woman is to ask her how she knows when menstruation begins. She will readily admit that she both feels and sees the bleeding as it arrives at the vulva. The observations of sensation and appearance will then be applied to all other observations the woman makes at the vulva. As the days go by she will recognize her patterns of fertility and infertility, according to the mucus patterns.

How To Conceive a Girl

The Shettles Method

Over the last twenty-five years, thousands of couples have turned to the Shettles method for learning how to conceive a girl. And thousands have been blessed with the girl they hoped for. In fact, the properly applied Shettles method gives couples at least a 75 percent success rate. Some researchers have reported success rates up to 90 percent!

In his book, Dr. Shettles discusses the issues which will help you learn how to conceive a girl. Some of the basic ideas are listed below, but you will need to purchase the book in order to get the full details as Dr. Shettles goes it to much more detail. Failure to follow his instructions lessens the chances of you conceiving a girl.

The Shettles Method is based on the fact that the Y chromosome bearing sperm ( boy sperm ) are smaller and less robust but move faster than the larger X chromosome bearing sperm ( girl sperm ).So based on this fact, the Shettle Method recommends the following to help you conceive a girl.

Determining the Time of Ovulation

Determining when you ovulate is vital when you are learning how to conceive a girl. Shettles recommends that you have sex 2 1/2 to 3 days BEFORE ovulation in order to increase your chances of conceiving a girl. Having sex closer to ovulation will dramatically decrease your chances of conceiving a girl. The timing of intercourse in relation to ovulation is a vital factor in increasing your chances of having a girl.

Shettles suggests three specific ways in which to do this.

1) Charting Cervical Mucus

Dr Shettes goes into full detail on how to chart your cervical mucus in Part Three of his book, How to Choose the Sex of Your Baby. You can download a blank CM chart in two different formats: PDF or Excel Spreadsheet.

With this method of determining when you ovulate, you access your cervical mucus on a daily basis. Right before you ovulate, your cervical mucus should be very watery and very elastic. It’s consistency should be that of raw egg white. Charting for more than a month before you attempt to conceive a girl is recommended so you can be CERTAIN that you are ovulating on a specific day.

2) Basal Body Temperature (BBT) Charting

Shettles also suggests that you use BBT charting a long with charting your cervical mucus in order to gain as much information in order to pinpoint when exactly you are ovulating. He goes into full detail on how to accurately chart your BBT in Part Three of his book. You can download a blank BBT chart in two different formats: PDF or Excel Spreadsheet. This chart also includes an area to record your Cervical Mucus assessments.

In order to chart your basal body temperature ( BBT ) you will need to purchase a basal thermometer. Before you get up each morning, you will take your temperature before you do ANYTHING. Any activity can lead to innacurate temperature readings. At the time of ovulation, you will see a spike in your temperature which will indicate that you have already ovulated. Considering that you need to have sex 2 to 3 days away from ovulation in order to increase your chances of having a girl, you will need to chart at least two months before you can make good use of the information that your charting reveals

3) Using Ovulation Predictor Kits

The final way Shettles recommends for finding out the exact time you are ovulating is by using ovulation predictor kits. These kits detect when your body has released LH (Luteinizing Hormone), a precursor to ovulation. Dr. Shettles suggests testing twice a day in to make sure you catch the surge as early as possible. He recommends testing once between 11am and 3 pm and then again between 5pm and 10pm. When all factors are considered, ovulation will most likely occur about 24 hours after the time when you get a positive result for the lh surge on your ovulation predictor kit. Dr. Shettles offers indepth explanations on how to interpret the ovulation predictor kits in his book so be sure to read all the information he provides.

Store bought ovulation predictor kits can cost quite a bit, but we offer them here at BabyHopes.com for a very reasonable price. You can read the product specification of our ovulation predictor kits on our product desription page.

Frequency and Timing of Intercourse

Shettles says in order to increase the chances of having a girl, you should have sex everyday from the end of your period up to 2 1/2 to 3 days before ovulation. After this point, do not have unprotected sex until several days past ovulation.

Intercourse further away from ovulation favors the larger slower moving X (girl) sperm. The weaker Y (boy) sperm will die more quickly in the more acidic preovulatory vaginal / cervical secretions and by the time of ovulation there will be a much larger concentration of X (girl) sperm available to fertilize the egg.

Sexual Position

Shettles suggests that if you are trying to conceive a girl, shallow penetration from your partner, preferably with the missionary position, will deposit the sperm closer to the entrance to the vagina. This area is more acidic than closer to the cervix and acidity will work against the weaker “boy” sperm leaving more “girl” sperm available to fertilize your egg.

Sex and Orgasms

When trying to conceive a girl, Shettles recommends that you don’t orgasm during sex as the body produces substances after orgasm that makes the vaginal environment more alkaline, which favors the “boy” sperm.

The contractions which accompany an orgasm help move the sperm up and into the cervix, giving the “boy” sperm an extra chance at being available when your egg is available for fertilization.

How to Conceive a Boy

The Shettles Method

The Shettles Method – How to Choose the Sex of Your Baby – Baby gender selection Over the last twenty-five years, thousands of couples have turned to the Shettles method for learning how to conceive a boy. And thousands have been blessed with the boy they hoped for. In fact, the properly applied Shettles method gives couples at least a 75 percent success rate. Some researchers have reported success rates up to 90 percent!

Dr. Shettles discusses the issues which will help you learn how to conceive a boy. Some of the basic ideas are listed below,. Failure to follow his instructions lessens the chances of you conceiving a boy.

The Shettles Method is based on the fact that the Y chromosome bearing sperm ( boy sperm ) are smaller and less robust but move faster than the larger X chromosome bearing sperm ( girl sperm ).

So based on this fact, the Shettle Method recommends the following to help you conceive a boy.

Determining the Time of Ovulation

Determining when you ovulate is vital when you are learning how to conceive a boy. Shettles recommends that you have sex as early as 24 hours before ovulation to no more than 12 hours past ovulation in order to increase your chances of conceiving a boy. Having sex too far in advance to ovulation will dramatically decrease your chances of conceiving a boy. The timing of intercourse in relation to ovulation is a vital factor in increasing your chances of having a boy.

Shettles suggests three specific ways in which to do this.

1) Charting Cervical Mucus

Dr Shettes goes into full detail on how to chart your cervical mucus in Part Three of his book, How to Choose the Sex of Your Baby. You can download a blank CM chart in two different formats: PDF or Excel Spreadsheet.

With this method of determining when you ovulate, you access your cervical mucus on a daily basis. Right before you ovulate, your cervical mucus should be very watery and very elastic. It’s consistency should be that of raw egg white. Charting for more than a month before you attempt to conceive a boy is recommended so you can be CERTAIN that you are ovulating on a specific day.

2) Basal Body Temperature (BBT) Charting

Shettles also suggests that you use BBT charting along with charting your cervical mucus in order to gain as much information as possible in order to pinpoint when exactly you are ovulating. He goes into full detail on how to accurately chart your BBT in Part Three of his book. You can download a blank BBT chart in two different formats: PDF or Excel Spreadsheet. This chart also includes an area to record your Cervical Mucus assessments.

In order to chart your basal body temperature ( BBT ), you will need to purchase a basal thermometer. Before you get up each morning, you will take your temperature before you do ANYTHING. Any activity can lead to innacurate temperature readings. At the time of ovulation, you will see a spike in your temperature which will indicate that you have already ovulated. Considering that you need to have sex as close to ovulation as possible in order to increase your chances of having a boy, you will need to chart at least two months before you can make good use of the information that your charting reveals.

3) Using Ovulation Predictor Kits

The final way Shettles recommends for finding out the exact time you are ovulating is by using ovulation predictor kits. These kits detect when your body has released LH (Luteinizing Hormone), a precursor to ovulation. Dr. Shettles suggests testing twice a day in to make sure you catch the surge as early as possible. He recommends testing once between 11am and 3 pm and then again between 5pm and 10pm. When all factors are considered, ovulation will most likely occur about 24 hours after the time when you get a positive result for the lh surge on your ovulation predictor kit. Dr. Shettles offers indepth explanations on how to interpret the ovulation predictor kits in his book so be sure to read all the information he provides.

Store bought ovulation predictor kits can cost quite a bit, but we offer them here at BabyHopes.com for a very reasonable price. You can read the product specification of our ovulation predictor kits on our product desription page.

Frequency and Timing of Intercourse

Shettles says in order to increase the chances of having a boy, you should have sex no earlier than 24 hours before ovulation to 12 hours after ovulation.

Intercourse closer to ovulation the faster but less robust Y (boy) sperm. The cervical mucus present at ovulation is less acidic and “slippery” enough to help the Y (boy) sperm reach the egg more quickly.

Sexual Position

Shettles suggests that if you are trying to conceive a boy, deep penetration from your partner, will deposit the sperm closer to the cervix giving the more aggressive and quicker moving “boy” sperm a head start to fertilizating the egg first.

Sex and Orgasms

When trying to conceive a boy, Shettles suggests that orgasms during sex are a good thing as the body produces substances after orgasm that makes the vaginal environment more alkaline, which favors the “boy” sperm.

The contractions which accompany an orgasm help move the sperm up and into the cervix, giving the “boy” sperm an extra chance at being available when your egg is available for fertilization.

Considerations for the Men

Have you drink a caffeinated beverage right before sex. This makes the Y-Sperm more active.

Pus in Semen

Pus cells in semen may be due to infection into genito-urinary tract due to any of the following causes:

Chlamydia Infection

Chlamydia is a common infection of genitourinary tract all over world. It’s a bacterial infection. The infection with bacteria decreases sperm count motility & fertilizing capacity of sperms. Complication of this can be epididymitis, and inflammation in the scrotum that may leave the man sterile. Chlamydia is the most common diagnosed STI and the number of new cases keeps rising. Young men and women aged 16 to 24 are most at risk although people of all ages can be affected.

Chlamydia is a sexually transmitted infection caused by a bacterium.

Chlamydia can be transmitted through oral and anal sex. It’s such a widespread disease that it is often known as the silent epidemic.

Chlamydia is the most commonly reported infectious disease and although curable is considered one of the most dangerous sexually transmitted diseases among men because of the far-reaching complications it can cause.

The reason chlamydia is so widespread and dangerous is because it often goes unrecognised and therefore is left untreated. Around 50% of men with chlamydia have no symptoms of the disease once infected. If left untreated it can cause infertility.

It is for this reason that regular testing is encouraged among sexually active men, particularly those under the age of 24. Statistics show that the most vulnerable and highest reported number of cases are men between the ages of 16 and 24.

Who is at risk?

Everyone who is sexually active, or who have been sexually active but has not been screened for chlamydia. Also, if you’ve had multiple sexual partners and fail to use contraception (condoms and dams) 100% of the time.

Chlamydia Prevention

You can get and spread chlamydia through unprotected oral and anal sex. This means you should approach sexual relationships or encounters responsibly, limit the number of sex partners, always use condoms or dams, and if you think you are or may be infected, avoid any sexual contact until you have been given the all-clear by your doctor or local GU/STI clinic. You also need to make sure your partner is treated to avoid the risk of re-infection.

Where can Chlamydia develop?

Chlamydia in men can initially develop in several areas of the body:

Urethra

Throat

Mouth

Rectum

Chlamydia Symptoms

Not everyone will experience every symptom outlined below, but some of you may experience one or more of the following (symptoms of chlamydia in men):

Pain, burning or stinging during urination

Pain or tenderness in the testicles

Clear, or slightly coloured discharge from the urethra

Unusual itching, particularly around the opening of the end of the penis

Low grade fever

In rare instances, chlamydia can infect the area in and around the rectum, producing inflammation and the production of a clear, sticky discharge from the rectum and, through not always, pain when going to the toilet.

Complications of Chlamydia infections in men

Sterility

Fertility problems

Epididymitis this is inflammation of the epididymis, the tube that carries sperm from the testicle. It can occur in one or both tubes and can result in extensive, very painful swelling

Reiter’s Syndrome, an autoimmune condition where the joints are affected by arthritis

Chlamydia Test

It is a very straightforward test which can be carried out either by your GP or at a GU/STI clinic. A swab from the urethra or throat should be sufficient to identify whether you are infected or a simple urine sample.

Gonorrhea (Gonococcal Urethritis)

Also called the “clap” or “drip,” gonorrhea is a contagious disease transmitted most often through sexual contact with an infected person.

Gonorrhea may also be spread by contact with infected bodily fluids, so that a mother could pass on the infection to her newborn during childbirth. Both men and women can get gonorrhea. The infection is easily spread and occurs most often in people who have many sex partners.

What Causes Gonorrhea?

Gonorrhea is caused by Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in mucus membranes of the body. Gonorrhea bacteria can grow in the warm, moist areas of the reproductive tract, including the cervix (opening to the womb), uterus (womb) and fallopian tubes (egg canals) in women, and in the urethra (the tube that carries urine from the bladder to outside the body) in women and men. The bacteria can also grow in the mouth, throat, and anus.

How Common Is Gonorrhea?

Gonorrhea is a very common infectious disease. In the U.S. each year, about 700,000 people are infected with gonorrhea, and about 75% of all reported gonorrhea is found in younger persons aged 15 to 29. The highest rates of infection are usually found in 15- to 19-year-old women and 20- to 24-year-old men.

How Do I Know If I Have Gonorrhea?

Not all people infected with gonorrhea have symptoms, so knowing when to seek treatment can be tricky. When symptoms do occur, they are often within 2-10 days after exposure, but can take up to 30 days and include the following:

Gonorrhea Symptoms in Women

Greenish yellow or whitish discharge from the vagina

Lower abdominal or pelvic pain

Burning when urinating

Conjunctivitis (red, itchy eyes)

Bleeding between periods

Spotting after intercourse

Swelling of the vulva (vulvitis)

Burning in the throat (due to oral sex)

Swollen glands in the throat (due to oral sex)

In some women symptoms are so mild that they escape unnoticed.

Many women with gonorrhea discharge think they have a yeast infection and self-treat with yeast infection medications purchased over-the-counter. Because vaginal discharge can be a sign of a number of different problems, it is best to always seek the advice of a doctor to ensure proper diagnosis and treatment.

Gonorrhea Symptoms in Men

Greenish yellow or whitish discharge from the penis

Burning when urinating

Burning in the throat (due to oral sex)

Painful or swollen testicles

Swollen glands in the throat (due to oral sex)

In men, symptoms usually appear 2-14 days after infection

How Is Gonorrhea Diagnosed?

Your doctor will use a swab to take a sample of fluid from the urethra in men or from the cervix in women. The specimen will then be sent to a laboratory to be analyzed. You also may be given a throat or anal culture to see if the infection is in your throat or anus. There are other tests which check a urine sample for the presence of the bacteria. You may need to wait for several days for your tests to come back from the lab.

Gonorrhea and chlamydia, another common sexually transmitted disease, often occur together, so you may be tested and treated for both.

How Is Gonorrhea Treated?

To cure the infection, your doctor will give you either an oral or injectable antibiotic. Your partner should also be treated at the same time to prevent reinfection and further spread of the disease.

It is important to take all of your antibiotics even if you feel better. Also, never take someone else’s medication to treat your illness. By doing so, you may make the infection more difficult to treat. In addition,

Tell anyone you have had sex with recently that you are infected. This is important because gonorrhea may have no symptoms. Women, especially, may not have symptoms and may not seek testing or treatment unless alerted by their sex partners.

Don’t have sex until you have completed taking all of your medicine.

Always use condoms when having sex.

What Happens If I Don’t Get My Gonorrhea Treated?

Untreated gonorrhea can cause serious and permanent problems in both women and men.

In women, if left untreated, the infection can cause pelvic inflammatory disease, which may damage the fallopian tubes (the tubes connecting the ovaries to the uterus) or even lead to infertility, and untreated gonorrhea infection could increase the risk of ectopic pregnancy (when the fertilized egg implants and develops outside the uterus), a dangerous condition for both the mother and baby.

In men, gonorrhea can cause epididymitis, a painful condition of the testicles that can sometimes lead to infertility if left untreated. Without prompt treatment, gonorrhea can also affect the prostate and can lead to scarring inside the urethra, making urination difficult.

Gonorrhea can spread to the blood or joints. This condition can be life-threatening. Also, people with gonorrhea can more easily contract HIV, the virus that causes AIDS. People with HIV infection and gonorrhea are more likely than people with HIV infection alone to transmit HIV to someone else.

How Does Gonorrhea Affect Pregnancy and Childbirth?

Gonorrhea in a pregnant woman can cause premature delivery or spontaneous abortion. The infected mother may give the infection to her infant as the baby passes through the birth canal during delivery. This can cause blindness, joint infection, or a life-threatening blood infection in the baby. Treatment of gonorrhea as soon as it is detected in pregnant women will lessen the risk of these complications. Pregnant women should consult a doctor for appropriate medications.

How Can I Prevent Infection?

To reduce your risk of infection:

Use condoms correctly every time you have sex.

Limit the number of sex partners, and do not go back and forth between partners.

Any genital symptoms such as discharge or burning during urination or an unusual sore or rash should be a signal to stop having sex and to consult a doctor immediately. If you are told you have gonorrhea or any other STD and receive treatment, you should notify all of your recent sex partners so that they can see a doctor and be treated.

Non-Specific urethritis or NSU (Non-gonococcal Urethritis)

It is caused by any of the following causative agent Chlamydia trachomatis, Ureaplasma urelyticum, Mycoplasma genitalium ,Candioda species, Anaerobes, Trichomonas vaginalis,, Unidentified / idiopathic. Some times it may be Persistent/recurrent non-gonococcal urethritis or Prolonged urethritis

What is NGU?

Nongonococcal urethritis (NGU) is sometimes called nonspecific urethritis (NSU). It is an infection of the urethra (the tube leading from the urinary bladder to outside the body). The symptoms of NGU are similar to gonorrhea, but the usual treatments for gonorrhea will not work.

What causes NGU?

NGU is caused by a bacterium called Chlamydia trachomatis. There are several other bacteria—including Ureaplasma urealyticum, Mycoplasma and Trichomonas—that can cause symptoms resembling those of NGU.

How does NGU spread?

NGU is a sexually transmitted disease (STD). It is passed from one person to another by unprotected sexual contact. It can be spread through vaginal sex, oral sex or anal sex.

What are the symptoms of NGU?

It usually takes one to three weeks after the infection occurs before a man develops any symptoms of NGU. The first symptom is usually a leakage of milky fluid (discharge) from the tip of the penis. The amount of discharge may vary from a little to quite a lot. There also may be mild burning of the penis during urination. If the symptoms are ignored, the discharge may decrease although the infection is still present. Sometimes there are no symptoms. If left untreated, the infection may move up around the testicles, causing pain, swelling and sterility. The infection also may spread to other parts of the body, causing severe illness.

How can I know if I have NGU?

If you think you have NGU, or any STD, contact your health care provider. He or she will examine you and perform tests, if necessary, to determine if you have an STD. A sample of fluid is taken from the penis and tested for the germs that cause gonorrhea and chlamydia. Notably, 20% of men with gonorrhea are co-infected with Chlamydia. Testing for HIV and other STDS should also be done in confirmed cases of NGU.

What should I do after being treated?

Make sure you take all of the medicine you have been given. Do not stop taking the medicine, even if your symptoms go away. Do not share your medicine with others.

Do not have sex until you have taken all of the medicine and you are sure that the discharge is gone.

Men can check themselves for discharge by gently squeezing the penis. The best time to do this is when you get up in the morning before you urinate. Clear fluid from the penis is normal. A discharge that looks like milk or pus means that you still have an infection. Don’t check for discharge more than once a day. Squeezing the penis more often may cause irritation and discharge even when there is not an infection.

Avoid reinfection by always using condoms for vaginal, oral and anal sex.

Contact all of the people with whom you have had sex during the last three months and advise them to get treated. Remember that there are other causes of NGU besides chlamydia. Even if your partner has a negative chlamydia test, he or she may still have given you the infection.

If the discharge doesn’t go away, or if it goes away and then comes back, return to your health care provider for further treatment.

Syphilis

What is syphilis?

Syphilis is a sexually transmitted disease (STD) or sexually transmitted infection (STI) that, when left untreated, can progress to a late stage that causes serious health problems. The infection alternates with periods of being active and inactive (latent). When the infection is active, symptoms occur. But when the infection is latent, no symptoms appear even though you still have syphilis.

Anyone who comes into close physical contact with a person who has syphilis can develop syphilis. You don’t have to have sexual intercourse to get syphilis-exposure can result from close contact with an infected person’s genitals, mouth, or rectum.

What causes syphilis?

Syphilis is caused by a type of bacterium (Treponema pallidum) that usually enters the body through the mucous membranes. An infected person can pass the disease to others (is contagious) whenever a sore or a rash is present.

What are the symptoms?

Symptoms of syphilis may not be noticed or may mimic those of many other diseases. This may cause an infected person to delay seeking medical care and can make diagnosis difficult.

The four stages of syphilis have different symptoms.

Primary stage: During this stage of syphilis, a painless open sore called a chancre (pronounced “shanker”) develops. Because syphilis is usually passed from person to person through sexual activities, chancres are often found in the genital area, anus, or mouth, but they may also be found wherever the bacteria entered the body.

Secondary stage: A skin rash and other symptoms occur during the secondary stage, which begins 4 to 10 weeks after the initial infection. Secondary syphilis is highly contagious through direct contact with the mucous membranes or other surfaces affected by the skin rash.

Latent stage: This stage is often called the hidden stage of syphilis because usually no symptoms are present. The latent stage is defined as the year after a person becomes infected. A person in early latent stage may be contagious. Many times, latent-stage syphilis is detected in a mother only after she gives birth to a child infected with syphilis (congenital syphilis).

Late (tertiary) stage: If syphilis is not detected and treated in the early stages, problems can develop because of damage caused by having the syphilis bacteria in the body for so many years. These may include heart disorders, mental disorders, blindness, other problems associated with the nervous system, and even death

How is syphilis diagnosed?

The first steps in diagnosing syphilis are discussing the history of your symptoms and sexual activities with a health professional and having a physical exam. The diagnosis of syphilis is usually confirmed with one of several blood tests.

How is it treated?

If detected and treated, syphilis can be cured with antibiotics. If not treated, syphilis may linger and may progress to the late stage where more serious health problems, such as blindness, heart disorders, mental disorders, nervous system problems, and even death, can occur.

What does the presence of pus cells in the semen signify?

Whether pus cells are present or not. While a few white blood cells in the semen is normal, many pus cells suggests the presence of seminal infection. Unfortunately, many labs cannot differentiate between sperm precursor cells ( which are normally found in the semen) and pus cells. This often means that men are overtreated with antibiotics for a “sperm infection” which does not really exist !

Some labs use a computer to do the semen analysis. This is called CASA, or computer assisted semen analysis. While it may appear to be more reliable (because the test has been done “objectively” by a computer), there are still many controversies about its real value, since many of the technical details have not been standardised, and vary from lab to lab.

Anti-Sperm Antibody

In some male’s, antibody production starts against its own sperms. These antisperm antibodies may then enter the testis & seminal fluid and ‘attack’ the sperms & sperm forming cells. These antisperm antibodies stick the sperms with each other and thus tend to seriously reduce sperm motility, thereby causing infertility. By the use of various treatments, the amount of antibodies may be reduced and fertility restored.

Antisperm antibodies have been found to be present in up to 40% of couples with unexplained infertility, and in 10% of unexplained male infertility. Infertility in a couple can occur if the woman’s cervical mucus provides a hostile environment by producing antibodies to her partner’s sperm. More often, the problem is due to the male partner producing antibodies against his own sperm. Unilateral or bilateral obstruction of the genital tract (either congenital or acquired), epididymitis and varicocele are also sometimes associated with an autoimmune response against spermatozoa.

What are Antisperm Antibodies?

Antisperm antibodies are one immune factor which could be involved in infertility. Antisperm antibodies are cells that fight against normal, healthy sperm. If you have antisperm antibodies, instead of seeing sperm as natural cells, your immune system fights against your sperm and destroys them. This prevents you from producing any viable sperm. Though still to be proven, there is evidence that antibodies against sperm can result in male infertility.

How Do Antisperm Antibodies Affect Fertility?

Antisperm antibodies can really impair the function of healthy sperm. These antibodies attach to your sperm, reducing motility and making it more difficult for sperm to pass through cervical mucus. Antisperm antibodies can also force sperm to clump together, making it difficult for your sperm to fertilize an egg.

Testing for Antisperm Antibodies

There are a variety of tests that can detect the presence of antisperm antibodies in the body:

Blood Tests: In women, blood tests are commonly used to detect the antibody.

Post-Coital Test: The post-coital test can detect the presence of antisperm antibodies in a woman’s cervical mucus.

Sperm Testing: In men, sperm testing is the best way to analyze for antisperm antibodies. The immunobead assay and the mixed agglutination reaction test are both used.

Treating Antisperm Antibodies?

There are a variety of treatments available to help couples struggling with antisperm antibodies to conceive.

Corticosteroids: Corticosteroids help to decrease the production of antisperm antibodies. Unfortunately, corticosteroids are associated with side effects, including hipbone damage.

Intrauterine Insemination(IUI): IUI can help couples to overcome antisperm antibodies as it allows sperm to bypass the cervical mucus. Fertility drugs can also be used.

In-Vitro Fertilization(IVF): IVF is the most successful treatment for couples with antisperm antibodies. This allows the sperm to be directly injected into the egg, without havng to travel throguh the uterus and fallopian tubes.

Less Semen Formation

Low Semen Levels

A reduced amount of ejaculated semen (less than 0.5 milliliters per sample) may be caused by a

Obstruction in the tube carrying the sperm from testis to outside i.e. structural abnormality in the tubes transporting the sperm.

Retrograde ejaculation: In which patient gets orgasm at normal time but semen in place of coming out through penile opening goes into bladder.

Absent Ejaculation or Orgasm: There are certain conditions in which patient does not get orgasm even after prolonged sexual activity. the cause of this can be primary, Psychogenic or due to certain medication, neurological diseases, surgeries etc. Treatment needs diagnosis of cause & then treatment.

Retrograde ejaculation: In which patient gets orgasm at normal time but semen in place of coming out through penile opening goes into bladder.

Absent Ejaculation or Orgasm: There are certain conditions in which patient does not get orgasm even after prolonged sexual activity. the cause of this can be primary, Psychogenic or due to certain medication, neurological diseases, surgeries etc. Treatment needs diagnosis of cause & then treatment.

Great Semen Health

Great male semen health is important.First of all the thing to work out is the health of your sperm as it is now. This means semen analysis.

Just so you know what you are in for here it is explained for you. The following is according to the World Health Organization (WHO ) on semen samples brought in for fertility testing.

APPEARANCE. What it looks like. A brownish tinge may indicate the presence of blood, while a yellowish color could be a sign of pus cells.

VOLUME. How much there is. After two days abstinence, there should be more than 2 ml of semen specimen.

VISCOSITY. Fluidity of the sample i.e., water has a low viscosity. Semen should have a fairly watery consistency at the time of testing (about one hour after ejaculation ).

LIQUEFACTION. Ejaculated semen coagulates on contact with air, and liquefies after a short time. This liquefaction should be complete at the time of testing (about one hour after ejaculation).

AGGLUTINATION. The semen sample is examined under a microscope. Presence of motile sperm stuck together is known as agglutination and may indicate antibodies.

MOTILITY. Percentage of sperm moving and how well they are moving. Motility is graded as follows:

Alkalinity or acidity of the sample (pH 7.0 is neutral). While semen pH increases over time, it should not be less than 7.2 at one hour.

SPERM COUNT. Total number of sperm (spermatozoa) present, usually recorded in millions of sperm per ml. Normal count is generally greater than 20 million sperm per ml of semen

WHITE CELL COUNT (pus), may be normally present in semen in small numbers, (i.e., less than one million per ml). Larger numbers may indicate infection, but not always.

VITALITY. Percentage of sperm which are alive (not the same as % of motile sperm). Motile sperm are obviously alive, whereas non-motile sperm may or may not be alive. At one hour, more than 50% of the sperm should be alive.

MORPHOLOGY. Examines individual stained spermatozoa samples under a microscope and determines what percentage is normal. A normal morphology level should be greater than 14%.

A semen analysis is the first step in semen health. Know where are are and then you will have a far better idea of what you have to do to get the semen health you want.

Treatment

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